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Best Practice for Home Care Group Residential Care and Assisted Living Residences During COVID-19 Residents of Massachusetts Assisted Living and other group Residences with confirmed COVID-19 or suspected COVID-19 returning from an acute care setting, or diagnosed in the community, with a need for clinical or personal care support, may find assistance though community home health and private home care. Assisted Living and other group Residential Care Facilities should expect that staff from the home care organizations entering their buildings and working with their residents are complying with the best operational practice guidance from the Centers of Disease Control (CDC) and Massachusetts Department of Public Health (DPH); such as self- monitoring, infection control, hand hygiene and don/doff Personal Protective Equipment (PPE) to name a few as outlined below: Note: during the COVID-19 public health emergency (PHE) private home care agencies must keep apprised of current guidance from CDC and DPH and have updated emergency preparedness plan and infection control policiesCare Giver TrainingAll caregiver staff is provided with the following training:Infection prevention and control practices and relevant updates regarding COVID-19 related to client careStandard precautions for all client care and transition-based precautions for clients with confirmed or suspected COVID-19Hand hygiene, including washing the hands with soap and water for at least 20 seconds, or use an alcohol-based hand sanitizer (at least 60% alcohol), which should occur at a minimum: on arrival at a client’s home before and after client contact before and after handling foodafter contact with the client’s immediate environmentafter contact with blood, bodily fluids and other potentially infectious material, or contaminated surfaceswhen soiled before and after putting on and taking off PPE, including, but not limited to, gloves and masksHow to Don/Doff PPE and how to dispose of PPECaregiver Personnel Self-screening and Client Assessment Before VisitCaregivers should monitor personal health daily, prior to seeing the first patient or beginning any client care. Caregivers are instructed to report new onset of fever (over 100 degrees Fahrenheit), cough, sore throat, shortness of breath, or any other symptoms of COVID-19 to agency for further instruction.Caregiver will be removed immediately from client schedules if symptoms are present and must contact a physician to report and obtain instructions for care; in addition to self-quarantine and medical follow up/testing, and agency procedures.Before making home visit to a new client, the agency personnel will call the to determine the client’s current COVID-19 clinical status, determine the necessary and appropriate type of PPE needed for the visit, and whether the client has PPE (what type) in the home. The assessment should include questions about possible exposure and signs and symptoms in the patient, household members, recent travel, and recent visitors, including: Have you had a fever in the past few days?Do you have a new or worsening cough today?Do you have any of these symptoms?Shortness of breath or difficulty breathingFatigueMuscle or body achesHeadacheSore throatCongestion or runny noseNausea or vomitingDiarrheaIs there anyone in your household or close contacts under investigation or surveillance or self-quarantine?Has any person in your household traveled internationally or in a high COVID-19 risk area?Care Giver TestingDue to the surmised potential for COVID-19 exposure in the home health setting, as workers travel to different client locations during each work day; it is essential that homecare workers?comply with infection control and prevention protocol to prevent the spread of COVID-19. There is no present data that attributes the increase spread of COVID-19 from home care workers to their clients/patients. The COVID-19 testing of health care workers/caregivers should not be seen as a substitute for good infection control processes to mitigate the transfer of the virus. The molecular testing provides the information of exposure/infection of the worker at that immediate point in time – but it does not provide a confidence level that the worker has not had an exposure since the testing. At this time, infection control confidence level is greater for workers who are following CDC and Massachusetts DPH guidance and who the appropriate PPE than a worker receiving weekly testing. Screening and Acceptance of Clients Who Have Been Diagnosed with COVID-19 A private care agency can accept a client diagnosed with COVID-19 and still under Transmission Based Precautions (as described by the CDC) for COVID-19 when:The agency has available PPE and staffing to be able to follow CDC infection prevention and control guidance.The client and other household members have access to appropriate, recommended personal protective equipment per CDC, at a minimum gloves and face covering, and are capable of adhering to precautions recommended as part of home care and isolation (e.g., respiratory hygiene and cough etiquette, hand hygiene and isolate the patient in a separate room from family).It is recommended that there is a separate bedroom/room, and preferably a separate bathroom, where the client can recover without sharing immediate space with others. If there is no separate room, (i.e. studio apartment) admit at agency discretion.Resources for access to food and other necessities are available.Personal Protective Equipment During Home Care Visits to Clients with No Signs and Symptoms of COVID-19:The caregiver uses standard precautions for all clientsUnder updated CDC and DPH guidelines, the caregiver should wear a facemask at all times while they are in the client’s home.Cloth face coverings should NOT be worn instead of a respirator or facemask as they are not considered PPEPersonal Protective Equipment for Clients with Signs and Symptoms of COVID-19, or with Positive COVID-19 Test, or Pending Test Results:The caregiver should don and doff PPE outside the home if possibleThe client should wear a facemask when they are around the caregiver and other people in the home. Facemasks should not be placed on young children under age 2, anyone who has trouble breathing, or is not able to remove the covering without help.As part of source control efforts, it is recommended that household members use face masks when in the presence of the client. The caregiver should attempt to stay at least 6 feet away from the client and household members to the extent possible, when not providing direct care. Hand hygiene must be performed before putting on and after removing PPE with a 20 second scrub with soap and water or using alcohol-based hand sanitizer that contains 60 to 95% alcohol.Gown, gloves, N95 respirator masks or equivalent, and face shield or goggles should be worn if the client or household members are experiencing symptoms of COVID-19. NOTE: According to DPH guidelines, the Food and Drug Administration (FDA) issued an update to the Non-NIOSH Approved Respirator Emergency Use Authorization (EUA) concerning non-NIOSH-approved respirators-. The KN95 respirators may be considered for use as a substitute for N95 respirators only if:N95 respirators are not available, and The KN95 respirators have been tested for filtration effectiveness, andThe use of KN95 respirators has been approved by the organization. If a N95 respirator or equivalent is not available, a facemask should be used. When to Discontinue Transmission-based Isolation PrecautionsAccording to CDC on July 17, 2020, test-based strategy is generally no longer recommended for determining when to discontinue transmission-based precautions in patients recovering from COVID-19 infection. These decisions can be made using a symptoms-based strategy that takes into consideration the severity of illness as outlined below: Clients with?mild to moderate illness?who are not severely immunocompromised:At least 10 days have passed?since symptoms first appeared?andAt least 24 hours have passed?since last?fever without the use of fever-reducing medications?andSymptoms (e.g., cough, shortness of breath) have improvedFor asymptomatic clients who are?not severely immunocompromised, Transmission-Based Precautions may be discontinued when at least 10 days have passed since the date of their first positive viral diagnostic test.Clients with?severe to critical illness?or who are severely immunocompromisedAt least 20 days have passed?since symptoms first appeared?andAt least 24 hours have passed?since last?fever without the use of fever-reducing medications?andSymptoms (e.g., cough, shortness of breath) have improvedFor clients who were?asymptomatic?throughout their infection, and severely immunocompromised Transmission-Based Precautions may be discontinued when at least 20 days have passed since the date of their first positive viral diagnostic test.Client Education and ReassuranceProvide CDC’s?Interim Guidance for Preventing Coronavirus Disease 2019 (COVID-19) from Spreading to Others in Homes and Communities?to the client and household membersClients should be advised to limit the number of in-person visitors, and to use the phone and social media as an alternative. CDC has educational materials online for the public in several languages. References (CDC and DPH guidelines)CDC Interim Guidance for Implementing Home Care of People Not Requiring Hospitalization for Coronavirus Disease 2019 (COVID-19) CDC Interim Guidance for Healthcare Facilities: Preparing for Community Transmission of COVID-19 in the United States Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings CDC: COVID-19 Fact Sheets : Preventing the Spread of Coronavirus Disease 2019 in Homes and Residential Communities Strategies for Optimizing the Supply of N95 Respirators: Conventional Capacity Strategies Discontinuation of Transmission-Based Precautions and Disposition of Patients with COVID-19 in Healthcare Setting (Interim Guidance) DPH’s Comprehensive Personal Protective Equipment (PPE) Guidance Comprehensive-PPE-Guidance-Prepared by the Home Care Alliance of MA based on CDC and MA Department of Public Health and industry expert best practice These are recommended Operational Protocols for private care agencies during the Public Health Emergency. Agencies are encouraged to create policies and procedures that reflect their own agency operations, capabilities, and client/community needs. ................
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