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San Francisco Health Network
COVID-19

In-person Visits, Communal Dining and Resident Activities for Adult & Senior Residential Care Facilities During COVID-19

 

 

The following guidance was developed by the San Francisco Department of Public Health for use by local facilities. This interim guidance may change as knowledge, community transmission, and availability of PPE and testing change.

AUDIENCE:  Administrators of all California Department of Social Services/Community Care Licensing Division licensed facilities in San Francisco. This includes Adult Residential Facilities (ARF), Residential Care Facilities for the Elderly (RCFE), Residential Care Facilities – Continuing Care, Social Rehabilitation Facilities, and Residential Care Facility for the Chronically Ill.

BACKGROUND:  Please see the State of California Department of Social Services Provider Information Notice (PIN) Summary 20-23-ACS and AFL 20-22.3, both issued on June 26, 2020, for updated guidance on COVID-19. This guidance includes the critical role of testing, modification of visitation guidelines, need for infection prevention and control, and use of face coverings in adult and senior care facilities.

San Francisco has stricter rules summarized in the box above and explained in further detail in this document. Additional information regarding preventing and managing COVID-19 can be found at Frequently Asked Questions (FAQs) for Residential Care Facilities for Adults and Seniors.

Sheltering in place is very important for people in high-risk groups, such as older adults and those with chronic medical conditions (see www.sfcdcp.org/vulnerable). Isolation is also a serious issue for older adults and that family and meaningful connection are important to mental and physical health.

Types of Visits

Two categories of visits are now permitted. In both circumstances, facilities must implement prevention and mitigation activities to reduce the risk of COVID-19 transmission:

"Necessary" visits may occur when there is an urgent health, legal, time-sensitive, or other critical need. These continue to be permitted under amended Health Order No. C19-09b.
"Allowed" visits by non-essential persons are now permitted under amended Health Order No. C19-09b under certain parameters.

Visits are further categorized as:

      o   Outdoor, in-person

      o   Facility, with visitor outside of facility and resident on the other side of a window. This may be an open window or a closed window visit.

      o   Vehicle, with visitor remaining in vehicle. An open window visit in this circumstance may mean that the resident is inside or outside of the facility. A closed window visit would mean the resident is inside of the facility behind a closed facility window.

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Summary of City & County of San Francisco Specific Guidance as of 08/31/2020

Please follow CDSS Update of 6/26/2020, with the following exceptions:

  • NEW: Outdoor, facility window, and vehicle visits are permitted by non-essential persons under  amended Health Order No. C19-09b (see section on "Allowed Visits") under certain parameters.
  • Indoor group activities are limited to 10 people, including staff or group leaders.
  • Re-introduction of resident communal dining has additional restrictions
  • Group activities are limited to small and stable groups; shared space requires spatial distancing
  • Monitor staff and residents for fever which is defined as a temperature of 100.0°F (37.8°C) or higher

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General Facility Visitation Prerequisites

The following criteria MUST be met to allow any visits by non-essential personnel.

Outdoor Visits, Facility Window Visits with an Open Window, Vehicle Visits with Open Window

  • No visitation for residents with symptoms, in isolation, or COVID+ and quarantine
  • Absence of any new COVID-19 cases in the facility for 14 days, either residents or staff, AND not currently in the surveillance period for an active outbreak
  • In the event of a new COVID-19 case at the facility Outdoor Visits and Open Window Visits must be Suspended/Postponed . Facilities with multiple units/floors may contact the DPH / Senior Sites1 to determine if the facility can safely cohort to allow visitation for residents in non-outbreak units.

 

Facility Window Visits with Closed Window OR Vehicle Visits with Closed Facility Window

  • Closed Window Visits are allowed as long as visitors do not walk through the facility
 

Outdoor Visits

For Outdoor Visits, facilities must comply with the following parameters:

Definition: Visitor and Resident are both in an outdoor setting. Visits to be supervised by facility staff at all times.
  • Visitation in outdoor settings only.
  • If weather does not permit, provide window or vehicle visits.
  • Visits must be preplanned; facility can determine visiting hours.
  • Visitors must wear masks. Residents must wear masks or other face coverings (as tolerated). 2
  • 6-feet or more physical distancing (no physical touching between resident and visitor such as hugging, hand-shaking, etc.). It is the facility's responsibility to monitor and ensure compliance.  It is required to put up signs and clearly mark areas to prevent groups of visitors from being too close to each other.
  • No more than 4 visitors from the same household. If visitors are from different households, the group should be limited to 2 visitors. Visitation group size can be determined based on facility space to allow for proper distancing and safety.
  • Visitation by children is left to the discretion of the facility.  If children are allowed to visit, all visitors ages 2+ should wear a face covering, and children must be under supervision at all times.  Screening should take into account the additional symptoms with which children may present.
  • Screen visitors for symptoms and related issues and conduct temperature prior to visit.
  • Perform hand hygiene in accordance with CDC guidelines (provide supplies as needed).
  • Routinely clean and disinfect all frequently touched surfaces.
  • Sharing items, including food, drinks, or utensils, during any visits is not permitted. If gifts are permitted, they must be approved by facility staff and processed by facility staff, providing an opportunity for disinfection and sanitization.
  • Visits must not exceed 1 hour and may be shorter if needed to accommodate residents while assuring compliance with visitation rules.
  • Whenever possible, visitation should take place without visitors walking through the facility or walking the shortest route through the facility.

Facility Window Visits

For Facility Window Visits, all facilities must comply with the following parameters:

  • Visits must be supervised by facility staff at all times.
  • Visits must be preplanned. Facility can determine visiting hours.
  • No more than 4 visitors from the same household. If visitors are from different households, the group should be limited to 2 visitors. Visitation group size can be determined based on facility space to allow for proper distancing and safety.
  • Screen visitors for symptoms and related issues prior to visit.
  • Facility should have a phone available to speak to resident at a safe distance.
  • If the resident must be taken to any of the designated areas, the resident must wear a mask (as tolerated)2 for that journey.
  • Whenever possible, visitation should take place without visitor(s) walking through the facility or walking the shortest route through the facility.
  • Sharing items, including food, drinks, or utensils, during any visit is not permitted. If gifts are permitted, they must be approved by facility staff and processed by facility staff, providing an opportunity for disinfection and sanitization.
  • Routinely clean and disinfect all frequently touched surfaces.
  • Visits must not exceed 1 hour and may be shorter if needed to accommodate residents while assuring compliance with visitation rules.
  • Visitation by children is left to the discretion of the facility.  If children are allowed to visit, all visitors ages 2+ should wear a face covering, and children must be under supervision at all times.  Screening should take into account the additional symptoms with which children may present.

Special Requirements for Facility Window Visits with an Open Window

Definition: Visitor(s) and Resident are separated by an open window with the Resident on the Facility side of a window and Visitor(s) outside on the other side.
  • Resident must stay at least 3 feet back from the window and wear a mask (as tolerated). 2
  • Visitors must stay at least 3 feet back from the window and wear a mask.
  • Facility should ensure that visitors seeing different residents can also keep at least 6 feet apart (limit crowding) and farther if needed so people can hear without shouting.  It is required to put up signs and clearly mark areas to prevent visitor(s) groups from being too close to each other.

Special Requirements for Facility Window Visit with a Closed Window

Definition: Visitor(s) and Resident are separated by a Window.  At all times, the facility window must remain closed so no air flow is exchanged.
  • If visitors are in an area were other people will be passing, visitors must wear masks.
 

Vehicle Visits

For Vehicle Visits, facilities must comply with the following parameters:

  • Visits to be supervised by facility staff at all times.
  • Visits must be preplanned. Facility can determine visiting hours.
  • Screen visitors for symptoms and related issues prior to visit.
  • Facility should have a phone available to speak to resident at a safe distance.
  • If the resident must be taken to any of the designated areas, the resident must wear a mask (as tolerated)2 for that journey.
  • Sharing items, including food, drinks, or utensils, during any visit is not permitted. If gifts are permitted, they must be approved by facility staff and processed by facility staff, providing an opportunity for disinfection and sanitization.
  • Routinely clean and disinfect all frequently touched surfaces.
  • Visits must not exceed 1 hour and may be shorter if needed to accommodate residents while assuring compliance with visitation rules.

Special Requirements for Vehicle Visits with Open Windows

Definition: Visitor(s), in a vehicle, and Resident are separated by at least 6 feet of distance where the Resident is in either an outdoor space or in the Facility behind an open window.
  • Resident should stay at least 6 feet back from the vehicle window and wear a mask (as tolerated). 2
  • Visitors must wear masks.
  • If there is a pull-in area for vehicle visits, the visits must be scheduled to prevent crowding and keep at least 6 feet between residents.
  • To reduce air flow to the resident, if possible, keep vehicle's window closest to the resident closed.

Special Requirements for Vehicle Visits with Closed Facility Windows

Definition: Visitor(s), in a vehicle, and Resident are separated by a Closed Facility Window.  At all times, the facility window must remain closed so no air flow is exchanged.
  • If visitors are in an area were other people will be passing, visitors must wear masks in the vehicle.

1Contact DPH Senior Sites with any specific questions. Email Seniorsites@sfdph.org or call 628-217-6358.

2Requirements for masks or face coverings are relaxed for residents as follows and for related/similar issues:  a diagnosis of dementia or grave mental illness; fear of/concern for suffocation, inability to remove or call for help, OR ordered by physician.

 

Alternatives to In-Person Visits

Encourage and create ways for all residents to have frequent video and phone call visits with family members, friends, or other persons in care. To the extent possible, find ways to connect with loved ones virtually through FaceTime, Zoom, WhatsApp, etc (see www.sfcdcp.org/safersocial).

If shared devices are used for video calls, facilities should ensure appropriate infection control measures are in place.

 

Communal Dining

Considerations for Re-introducing Communal Dining:

  • Ramp up slowly. Plan to start with a single group and assess how it goes, then stagger small groups, one at a time.
  • Give residents a choice about where they want to eat, offering new, safe dining room options as well as 'grab and go' and in-room dining.
  • Consider creating a schedule initially so different groups use the dining room for specific meals on specific days.
  • Servers/staff must wear masks at all times.
  • Have staff eat at separate times, so that they do not remove their face coverings at that same time as residents or other staff.
  • Staff training and supervision will be essential to the success of dining room reopening.

Residents should take the following precautions:

  • Wear masks when going to and leaving from the dining room. Residents may remove their masks to eat.
  • Residents should perform hand sanitation upon entering the dining room and before leaving.

If there is more than one group of residents in a shared dining space, implement the following mitigating measures:

  • Divide residents into pod/groups of 6 or fewer people; multiple groups of 6 are permitted in the same space if it is large enough to allow for sufficient distancing.
  • Residents who live in the same room/apartment must be in the same group.
  • Maintain the same people in each group to limit the people who are exposed to one another without masks.
  • To ensure that residents are able to maintain at least 6 feet distance, position tables for different groups approximately 12 feet apart.
  • Remove chairs and move tables so that groups of more than 6 are not possible.
  • Keep groups separate for dining, and going to/leaving from the dining room
  • Use either disposable plates and utensils or machine wash all of one group's flatware, silverware and glassware, whether it was used or not.
  • Condiments, including salt and pepper, should be provided in individual packets or bowls upon request. No supplies should be on the table for group use.
  • Stagger dining room times for different groups to reduce the number of persons dining at the same time or on elevators at the same time.
  • Fully sanitize the dining room before and after each group.

Residents should not participate in communal dining if:

  • The resident has any symptoms of COVID-19
  • The resident has close contact with anyone from outside of the facility
  • Any staff or resident in the facility tests positive for COVID-19, pending full evaluation and DPH contact tracing.

Per CDSS, residents who test positive for COVID-19 should not participate in communal dining until they have a negative test result.

 

Resident Activities

Residents may engage in small group activities. Small group size should be limited to 10 people including the instructor/leader. Consider prioritizing activities that meet the following safety guidelines AND support the quality of life of the frailest, most isolated residents who are least able to access other sources of support and activity.

  • Any activities that can be done outdoors should be done outdoors.
  • Staff are responsible to ensure social distancing, masking, and hand hygiene are performed correctly.
  • Maintain required staffing ratios to ensure safety. Do not move staff from one group to another, if possible.

For large indoor spaces like dining rooms or auditoriums, more than one group may use the space if:

  • The space has at least 144 square feet (12' x 12') per resident, or about 1750 square feet for a group of 12.
  • The designated areas for each group are clearly marked, and separated by a 10-12 feet "no-go" buffer zone that neither group uses and residents are able to understand and respect the zones.
  • The space can be adequately ventilated, for example, by opening windows or doors.
  • Partitions are placed to keep air from flowing directly from one group to another. For example, a curtain could be used.

If there is more than one group of residents in a shared space, follow these additional safety precautions:

  • Different groups should arrive and depart separately.
  • The space should be cleaned thoroughly between groups.
  • Schedule group activities in a staggered fashion to limit number of residents participating and allow them to remain at least 6 feet apart from each other.

When choosing activities that will take place in the shared space, consider the potential to create respiratory droplets or aerosols, and try to do higher-risk activities outdoors. For example, higher vocal tasks, such as shouting and singing should be avoided. These vocal exercises are higher risk than quiet, sedentary activities.

 

Frequently Asked Questions

My father is in hospice care.  If the facility reports a case and must postpone future non-essential visitation, may I still visit with him?

 "Necessary Visitation" is a provision of Health Order No. C19-09In a situation where a visit or contact is based on urgent health, legal, time-sensitive or critical need, Section 11 of Health Order No. C19-09 permits visitation. This may include, for example, when a resident is in marked decline and/or the end stages of life.

Permitted visitors are required to take appropriate steps to protect residents from exposure to the COVID-19 virus, which includes hand washing, masking, maintaining at least six feet distance from other people, limiting or avoiding physical contact, and a short duration of visit as appropriate.

 
What should a facility do if a resident, visitor or staff has confirmed COVID-19 infection?

Contact the SFDPH Senior Hub for consultation and guidance at COVID-19 Senior Sites Phone Line: 628-217-6358 or COVID-19 General Phone Line: 415-554-2830 Email: seniorsites@sfdph.org

Stop all visits and group activities, including communal dining; reinstitute full shelter in place.

Communicate with residents, visitors and staff: Share that there is a case but not who is sick or has tested positive. Maintain the confidentiality of the affected person with COVID-19 as required by the Americans with Disabilities Act, the Family Education Rights and Privacy Act, and possibly HIPAA.

Clean and disinfect the facility thoroughly, with special attention to anywhere that person was or might have been. Refer to the section titled "Cleaning and disinfecting your building or facility if someone is sick" at CDC's Cleaning and Disinfection webpage, at www.cdc.gov/coronavirus/2019-ncov/community/disinfecting-building-facility.html.

Work with SFDPH to determine when the facility can re-open for visits. Determine when staff can return, and what additional steps are needed for children and youth to return.

 

Resources

Stay informed.  Information is changing rapidly.

SFDPH
  • SFDPH guidance for home care providers, home isolation and returning to work, and more: www.sfcdcp.org/covid19
California Department of Public Health
Centers for Disease Control and Prevention (CDC)
SF Human Services Agency: