Please find details on a wide array of our COVID mitigation policies below.

If you have any questions regarding how Royal Health is responding to the COVID-19 crisis, please email us at

Control Measures

  • Hand Hygiene
    • HCP should perform hand hygiene
      • before and after all patient contact,
      • contact with potentially infectious material, and
      • before putting on and after removing PPE, including gloves.
      • after removing PPE, it is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process.
    • HCP should perform hand hygiene by using
      • ABHR with 60-95% alcohol or
      • washing hands with soap and water for at least 20 seconds. If hands are visibly soiled, use soap and water before returning to ABHR.

Personal Protective Equipment

  • Residents are to wear masks as tolerated when staff enter room.
    • All residents are to wear a mask, if tolerated, outside their room and whenever they leave facility for appointments.
    • Resident may use tissue to cover nose and mouth if unable to tolerate a mask.
    • Precautions signs which include required PPE will be posted on resident door or unit if designated unit.
    • Types of PPE include:
      • Respirator or Facemask
        • A facemask is always required in the facility with exception of being alone in an office with the door closed.
        • N95 respirators or respirators that offer a higher level of protection should be used instead of a facemask when performing or present for an aerosol-generating procedures on confirmed or suspected COVID-19 residents.
        • Disposable respirators and facemasks should be discarded at end of shift
        • In situations of limited supply, HCP shall keep disposable mask on between rooms as long as they do not remove, and mask is not soiled or contaminated.
        • Perform hand hygiene after touching or discarding the respirator or facemask.
        • If tolerated, have resident wear mask if they must leave their room.
  • Eye Protection/Face Shield
    • Eye protection or face shield should be worn with all resident encounters and in all resident areas, including unit hallways.
    • Personal eyeglasses and contact lenses are NOT considered adequate eye protection.
    • Perform hand hygiene after touching eye protection/face shield.
    • Wipe down face shields when leaving a positive wing.
    • Reusable eye protection must be cleaned and disinfected according to manufacturer’s reprocessing instructions prior to re-use.
    • In situations of limited supply, HCP shall keep eye protection/face shields on between rooms as long as they do not remove, or mask is soiled or contaminated.
    • Gloves
      • Gloves should be worn per PPE Grid.
      • Change gloves between residents and if they become torn or heavily contaminated during care.
      • Remove and discard gloves as you leave the patient room or care area and perform hand hygiene.
    • Gowns
      • Put on a clean gown per appropriate PPE guidelines..
      • Change the gown if it becomes soiled.
      • Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area.
      • Disposable gowns should be discarded or washable gowns placed in bin after caring for PUI or negative residents during outbreak, or leaving a COVID-19 wing.
      • Cloth gowns should be laundered after each use.
      • If there are shortages of gowns, they should be prioritized for:
        • aerosol-generating procedures
        • care activities where splashes and sprays are anticipated
        • high-contact patient care activities that provide opportunities for transfer of pathogens to the hands and clothing of HCP. Examples include:
          • dressing, bathing, grooming, transferring
          • changing linen/briefs or assist with toileting
          • wound care, device use

PPE Inventory

  • Designated reuse PPE will be stored in clean rooms/stations, disinfected after each use.
  • PPE supplies will be readily accessible on all units. For Quarantine residents, PPE bins will be outside resident room. It is permissible to place bin in between two rooms due to limited supply.
  • Facility staff to report PPE shortage to PPE Coach, supervisor or Administrator immediately.
  • Covered trash disposal bins are positioned as near as possible to the exit inside of the resident room so staff can easily dispose of PPE after removal prior to exiting the room. Trash bins may be place outside room for dementia residents. 
  • Facilities will determine 2 week needs by multiply 2-day use by 7. 
  • Facility will have minimum of 7-day supply on-site and 7-day supply at corporate site.
  • Facilities continue to order PPE (surgical face masks, gowns, and gloves) through current vendors when directed by Director of Procurement. 
  • Facilities are to update supply inventory list so Director of Procurement identify needs. 
  • Director of Procurement and Regional Support Staff review inventory frequently to identify needs and if there is an emergent need from any facility, they will transfer supplies from stockpile to the facility. 
  • Director of Procurement has and will continue to procure PPE (face masks, N95 masks, gowns, gloves and googles/face shields) as back-up to facility procurement. 
  • Facilities will request supplies through Local, State and Federal agencies weekly as needed. 

PPE Coaches, Education and Compliance

  • Staff have been trained and demonstrate competency regarding appropriate PPE, donning and doffing. 
  • Facilities will conduct random audits to ensure compliance with PPE. 
  • Facility will designate PPE Coaches to identify and support adherence with PPE policies.
    • PPE Coaches will be assigned on all shifts and designated on the schedule.
    • PPE Coaches will observe HCP to ensure they are wearing appropriate PPE, and donning and doffing appropriately during the shift. 
    • Using the On The Fly education form, PPE Coach will provide real-time education when non-compliance identified, and document same. 
    • PPE Coach will use the Monitoring Tool for Handwashing and PPE Use to document observations, compliance and education. Tools will be submitted to the Infection Control Lead or Staff Developer for further review and additional education if necessary.

Train and Educate Healthcare Personnel

  • The facility will assign an Infection Control Preventionist (ICP) to address and improve infection control measures based on public health advisories (federal and state).
  • The ICP will spend adequate time in the building focused on activities dedicated to infection control. 
  • The ICP will participate in communications with regional support team and peers to review new or revised federal or state guidance and review facility status updates. 
  • Ensure staff are educated on COVID-19 signs and symptoms and Infection Control Measures, including hand hygiene.
  • Ensure that HCP are educated, trained, and have practiced the appropriate use of PPE prior to caring for a patient, including attention to correct use of PPE and prevention of contamination of clothing, skin, and environment during the process of removing such equipment.

Employee and Visitor Screening

  • The facility will assign screeners to question employee or visitor for symptoms of illness using screening tools.
  • The screener is educated in infection control measures prior to screening employees, providers or visitors. 
  • The screener knowledge will be validated with Competency Tool.
  • The screener will wear appropriate PPE. 
  • When visitor/employee complete a portion of the screening tool facility will be two containers for pens when visitors are expected to complete a portion of the form. One for clean pens and one for used pens. The screener will disinfect used pens with an approved disinfectant and place in clean container. 
  • Reception/screening area will be disinfected frequently while screener is present/individuals entering the building.
  • PPE area/room will be disinfected at least twice daily. 

Screening Employees

Facility will actively verify absence of fever and respiratory symptoms when employees enter the building to start their shift. Document temperature, absence of shortness of breath, new or change in cough and sore throat and other criteria as identified by State guidance.

  • Employees include contracted employees and vendors such as Hospice workers, non-emergent EMS personnel or dialysis technicians, who provide care to the residents.
  • Employees who develop symptoms to COVID-19 (fever, cough, shortness of breath or sore throat and other criteria as identified by State guidance) will be instructed to not report to work. Testing will be coordinated and medical evaluation recommendations and return to work instructions will be provided.
  • Employees who develop symptoms on the job will be instructed to immediately stop work, notify supervisor, immediately leave the facility and instructed on self-isolation at home.
  • Infection Preventionist will frequently check in with employee.
  • The Infection Preventionist will work with the employee to identify individuals, equipment and locations the employee came in contact with.
  • The Infection Preventionist will contact the local and/or state health department for recommendations on next steps.
  • The facility will identify employees that work at multiple facilities and make attempts to limit their work to one facility, when possible.

Screening Visitors

Facility will actively verify absence of fever and respiratory symptoms. (Document temperature, absence of shortness of breath, new or change in cough and sore throat and other criteria as identified by State and CDC guidance 

  • Visitors include end of life visits, essential provider visits, and scheduled social visits. 
  • Screen visitors for symptoms of acute respiratory illness before entering the healthcare facility.
  • Limit points of entry to one entrance. 
  • Visitor will not be permitting in facility if fever, respiratory symptoms or close contact with someone with COVID -19 with 14 days. 
  • Facility will request proof of test per State guidelines if visitor traveled from non-bordering high-risk state. Should proof not be available, consult facility administration.
  • Inform visitors about appropriate PPE use according to current facility visitor policy. 
  • Visitors with known or suspected COVID-19 will be restricted from facility.
  • Facility will obtain visitor contact information, if not already recorded in medical record, for contact tracing.

Resident Monitoring and Management

  • If resident is newly admitted, symptomatic or confirmed COVID-19, monitor temperature, respiratory rates, oxygen saturation and other COVID-related symptoms every four hours on days and evenings, and once on nights.
  • All residents will be asked if they are experiencing COVID-19 symptoms and have temperature taken a minimum of twice per day.
  • Notify nurse if resident is showing any symptoms.
  • If there is an outbreak in facility:
    •  Monitor all positive residents -temperature, respiratory rates, oxygen saturation and other COVID-related symptoms- every four hours on days and evenings, and once on nights.
    • Continue to monitor all other residents twice a day, once on days and once on evenings.
  • If a resident requires a higher level of care or the facility cannot fully implement all recommended precautions, the resident should be transferred to another facility that is capable of implementation. Transport personnel and the receiving facility should be notified about the suspected diagnosis prior to transfer.
    • While awaiting transfer, symptomatic residents should wear a facemask (if tolerated) and be separated from others (e.g., kept in their room with the door closed). Appropriate PPE should be used by healthcare personnel when coming in contact with the resident.
  • Encourage residents to remain in their room with door closed.
  • If there are cases in the facility, restrict residents (to the extent possible) to their rooms except for medically necessary purposes.
  • Patients should wear a facemask to contain secretions during transport. If patients cannot tolerate a facemask or one is not available, they should use tissues to cover their mouth and nose.
  • Remind residents to practice social distancing and perform frequent hand hygiene.
  • Residents will be requested to wash hands prior to leaving room and before and after meals/activities.

Resident Placement

  • For patients with COVID-19 or other respiratory infections, evaluate need for hospitalization (See Section on Emergency Transfers).
  • Residents who are confirmed positive are separated from residents who are not/have not been infected or have an unknown status. Facilities will separate as follows: 
    • Designated separate units for COVID-19 positive residents, 
    • If not possible to designate a whole unit, designate a section/space of a unit for COVID-19 residents, 
    • If not possible to designate a section of a unit, positive COVID-19 residents must be placed with other positive COVID-19 residents.
    • Resident may be placed in room with another confirmed resident. Close privacy curtain as a barrier.
  • Residents who are 6 mos post-recovered (over 6 mos from infection) or are not suspected to be infected with COVID-19 are in rooms or spaces that do not include confirmed or suspected cases. 
  • Residents who are symptomatic shall be moved to isolated/quarantined area/room with separate bathroom pending test results and moved to appropriate room once results are known. Door should remain closed.
  • New admission or readmission residents, who are not recovered within previous 6 months, will be quarantined in a single-person room for 14 days to monitor symptoms. The resident should have a separate bathroom. If unable to provide private room, may be roomed with resident who is recovered (less than 6 mos from infection) in a dedicated quarantine space. Privacy curtain closed, and equipment cleaned between residents.
  • It might not be possible to distinguish residents who have COVID-19 from residents with other respiratory viruses. As such, residents with different respiratory pathogens will likely be housed on the same unit. However, only residents with the same respiratory pathogen may be housed in the same room. For example, a resident with COVID-19 should be housed with a resident with COVID-19 if possible, not be housed in the same room as a resident with an undiagnosed respiratory infection. 
  • Facility Infection Preventionist and clinical team will review room placement daily to ensure proper cohorting based on symptom screening, temperatures, and surveillance testing if available. 
  • For positive, symptomatic, quarantine residents, 6-month post recovered, and negative residents when there is community spread: 
    • Post Special Droplet Precaution sign on resident door, place covered trash and laundry bins in room close to door, and precaution cart outside room. 
    • Personnel entering the room should wear appropriate PPE (see PPE Grid) 
    • Once the resident has been discharged or transferred, HCP should refrain from entering the vacated room until terminally disinfected. 
  • Residents who are in recovery may be moved to (See section on Discontinuation of Transmission-based precautions): 
    • Recovery unit if available 
    • If recovery room is not available, resident may move to a negative room ideally with another recovered resident.
    • If recovered roommate is not possible, recovered resident may be placed in room with a negative resident.
    • If facility does not have a recovery unit or space unavailable, resident may stay on the positive space/room until an appropriate room is available.
  • As a measure to limit HCP exposure and conserve PPE, facilities shall have dedicated HCP when possible, to care for known or suspected COVID-19 patients. Dedicated means that, when possible, HCP are assigned to care only for these patients during their shift.
    • Determine how staffing needs will be met as the number of patients with known or suspected COVID-19 increases and HCP become ill and are excluded from work.
    • If possible, do not float personnel to other units if isolated to one unit.
    • During times of limited access to respirators or facemasks, facilities could consider having HCP remove only gloves and gowns (if used) and perform hand hygiene between patients with the different statuses while continuing to wear the same eye protection and respirator or facemask (i.e., extended use).
    • Risk of transmission when using eye protection and facemasks during extended use is expected to be very low.
      • HCP must take care not to touch their eye protection and respirator or facemask.
      • Eye protection and the respirator or facemask should be removed, and hand hygiene performed if they become damaged or soiled and when leaving the unit.
    • HCP should strictly follow basic infection control practices between patients (e.g., hand hygiene, cleaning and disinfecting shared equipment).
    • Personnel entering the room should use PPE according to PPE Grid.

Removing Residents from Precautions

  • Per CDC, the decision to discontinue transmission-based precautions should be made using the following symptom-based strategy:

Patients with mild to moderate illness who are not severely immunocompromised:

  • At least 10 days have passed since symptoms first appeared and
  • At least 24 hours have passed since last fever without the use of fever-reducing medications and
  • Symptoms (e.g., cough, shortness of breath) have improved

For patients who are not severely immunocompromised and who were asymptomatic throughout their infection, Transmission-Based Precautions may be discontinued when at least 10 days have passed since the date of their first positive viral diagnostic test.

Patients with severe to critical illness or who are severely immunocompromised:

  • At least 10 days and up to 20 days have passed since symptoms first appeared and
  • At least 24 hours have passed since last fever without the use of fever-reducing medications and
  • Symptoms (e.g., cough, shortness of breath) have improved
  • Consider consultation with infection control experts

Mild Illness is defined as any of the various signs and symptoms of COVID-19 without shortness of breath, dyspnea, or abnormal chest imaging.

Moderate Illness is defined as evidence of lower respiratory disease by clinical assessment or imaging, and a saturation of oxygen (SpO2) ≥94% on room air at sea level.

Severe Illness is defined asrespiratory rate >30 breaths per minute, SpO2 <94% on room air at sea level, or lung infiltrates >50%.

Critical Illness is defined as respiratory failure, septic shock, and/or multiple organ dysfunction.

CDC defines severely immunocompromised as:

  • Some conditions, such as being on chemotherapy for cancer, being within one year out from receiving a hematopoietic stem cell or solid organ transplant, untreated HIV infection with CD4 T lymphocyte count < 200, combined primary immunodeficiency disorder, and receipt of prednisone >20mg/day for more than 14 days, may cause a higher degree of immunocompromise and inform decisions regarding the duration of Transmission-Based Precautions.
  • Other factors, such as advanced age, diabetes mellitus, or end-stage renal disease, may pose a much lower degree of immunocompromise and not clearly affect decisions about duration of Transmission-Based Precautions.
  • Ultimately, the degree of immunocompromise for the patient is determined by the treating provider, and preventive actions are tailored to each individual and situation.

Patients with confirmed COVID-19 can be discharged from the healthcare facility whenever clinically indicated.

  If discharged to home:

  • The decision to send the patient home should be made in consultation with the patient’s clinical care team and local or state public health departments. It should include considerations of the home’s suitability for and patient’s ability to adhere to home isolation recommendations.

  If discharged to a nursing home or other long-term care facility (e.g., assisted living  facility), AND

  • If Transmission-Based Precautions are still required, the patient should go to a facility with an ability to adhere to infection prevention and control recommendations for the care of residents with SARS-CoV-2 infection. Preferably, the patient would be placed in a location designated to care for residents with SARS-CoV-2 infection.
  • If Transmission-Based Precautions have been discontinued, the patient does not require further restrictions, based upon their history of SARS-CoV-2 infection.

Admission Policy during COVID-19 Pandemic

The facility acknowledges that when a long-term care facility resident is transferred from a long-term care facility to a hospital for evaluation of any condition, including but not limited to COVID-19 care, each long-term care facility must accept the resident’s return to the facility regardless of COVID-19 status when the resident no longer requires hospital level of care as long as the facility can meet the needs of the resident. 

  • Massachusetts Homes:
    • All admissions and readmissions will be quarantined for fourteen days per DPH guidance. This includes residents post 6 months recovered.
    • If positive test at the hospital, resident may be admitted directly to positive facility/space. 
    • Residents who are less than 6 months recovered do not need to be quarantined if they meet the criteria of 10d/24hrs. 
    • If symptom-free status cannot be determined, isolate for three days upon return.
  • Rhode Island Homes:
    • Asymptomatic or status unknown residents must have one negative swab during hospital stay and must be quarantined for 14 days upon admission to facility. 
    • ER transfers must be asymptomatic however test is not required.
    • Positive residents must be in recovery and have two negative swabs 24 hours apart prior to being discharged to facility. 
    • Admission/readmission in recovery (less than 6 months) do not need to be quarantined as long as they meet the recovery criteria.

Whenever possible, hospitalized patients who are confirmed to be infected with COVID-19 and require skilled nursing level of care should be admitted to a designated COVID-19 nursing home or a facility with a designated COVID-19 isolation wing or unit.

Emergency Transfers to Acute Care During COVID-19 Pandemic

Emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident(s). All attempts will be made to utilize whatever resources available to treat our residents in the facility. Risk & benefit of sending residents to the acute care facility will be discussed with MD & family. 

  • Residents will not be transferred unless: 
    • The transfer or discharge is necessary for the resident’s welfare if the resident’s needs cannot be met in the facility; 
    • The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; 
    • The health of individuals in the facility would otherwise be endangered; 
    • If a resident is unable to be stabilized at the facility whether due to Advance Directives or clinical stabilization such as being unable to maintain Oxygen saturation.
  • Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: 
    • Consult with the resident’s Attending Physician to determine if medical needs can be met in facility or hospitalization is necessary; 
    • Notify the receiving facility that the transfer is being made and the Covid -19 status of the resident 
    • Prepare the resident for transfer. If Covid positive resident must have a mask on if able to tolerate 
    • Prepare a transfer form to send with the resident; 
    • Notify the representative (sponsor) or other family member; 
    • Notify EMS of resident’s clinical status as well as Covid status 
    • Notify others as appropriate or as necessary. 
  • Should it become necessary to transfer residents during emergency or disaster situations, transfer procedures outlined in our disaster plan will be implemented. 

Communal Dining and Activities

General Policies

  • The facility must have adequate PPE and essential cleaning supplies to disinfect the areas. 
  • Only residents who have fully recovered from Covid-19 and those residents not in isolation for suspected or confirmed Covid-19, and those residents not currently quarantined due to exposure or new admission can participate in communal dining. 
  • Residents with any signs or symptoms of respiratory infection will not be permitted in the dining room or to attend activities. Residents to be visually assessed or asked about symptoms prior to leaving room.
  • Residents for which it is not contraindicated to wear a mask should be masked (with a cloth mask at minimum) when they are in transit to the dining room or activity space.
  • Residents will be educated on washing their hands with soap and water prior to leaving their rooms and staff will observe residents practicing hand hygiene (including 60% +alcohol-based sanitizer or sani-wipes) again as they leave the dining room or activity.
  • If resident unable, staff will wash resident hands as described above.
  • Physical distance must still be maintained. Residents positions when seated in the dining room or in indoor/outdoor activity space must be no less than six feet apart for each other.
  • When possible, residents will be seated at the same table each day to continue to minimize resident contact. 
  • Whenever possible, only one staff member will serve food to the dining room to continue to minimize staff/resident interaction.
  • Meals will be served individually (no family style dining). 
  • No sharing of condiments or utensils.
  • When possible, a staff member will be designated to clear dishes and will be different from the one serving.
  • During any activity, equipment/supplies will not be shared. 
  • Table and chair must be cleaned and disinfected using an EAP List-N approved product before and after each meal or activity.
  • Activities staff and staff that assist in dining will be trained and educated on use of an EPA List-N cleaner including when, where, and how it needs to be used.

Massachusetts specific guidance

  • The facility must not have severe staffing shortages that caused implementation of a contingency staffing plan. 

Rhode Island specific guidance


  • Residents will be cohorted into groups of 5 based on their relationships with other residents and type of activities they enjoy and those groups shall not intermingle for the purposes of activities.
  • To the extent possible staff will stay with specific groups in order to minimize contact. No staff member will hold more than one group activity per day.

Therapy Gyms

Facilities may utilize indoor exercise or gym space for the purposes of physical, occupational or other clinically indicated therapy if the following conditions are met: 

  • Only residents who have fully recovered from COVID-19, are in quarantine due to being a new admission, and those residents not in isolation for suspected or confirmed COVID-19 status can participate in clinically indicated therapy. 
  • The facility must have adequate supplies of PPE and essential cleaning and disinfection supplies to care for residents. 
  • The facility must not be under a contingency staffing plan. 
  • Therapist to follow PPE guidance according to resident and facility status. 
  • Residents must wear a surgical mask during transport to and from therapy and in the therapy space. 
  • Residents must be 6 feet away from other residents and therapists at all times. 
  • Therapist will assist resident with hand hygiene prior to leaving resident room and when leaving therapy space. 
  • Equipment will not be shared between residents occupying the gym at the same time. 
  • Therapist will disinfect all equipment used before and after use. 
  • Therapist will disinfect the space used, including all high touch areas between resident treatments. 
  • Family members of caregivers may be permitted in the therapy space under the following conditions: 
    • Family members or caregivers may participate in discharge education and training when necessary to safely learn how to care for their loved one at home. 
    • Discharge education should only include necessary participants who must stay 6 feet away from resident and staff when not engaging in activities such as demonstrating resident transfers. 
    • Family members or caregivers will be screened and given appropriate PPE. 
    • Resident to wear mask at all times. 
    • Training will occur outside if permissible, in a designated indoor space or in therapy space provided no other residents or staff are present.
    • Space, utilized equipment and high-touch areas will be disinfected using an EPA-registered disinfectant before and after training. 
  • Facility has the discretion to suspend therapy in gyms or elsewhere due to suspected or confirmed outbreak. 

Community Outings

Community outings are strongly discouraged as these activities increase the risk of residents contracting COVID-19 from the community at-large and introducing it into the facility.

Facilities offer will offer alternatives, such as:

  • Video chats
  • Reschedule non-essential appointments 
  • Conduct Telehealth appointments
  • Coordinate on-site non-essential services with facility administration
  • Utilize medical transportation for necessary medical appointments 

Procedure for medical appointments without medical transportation services and non-medical outings: 

  • Residents who are positive or symptomatic are restricted from non-emergent travel. 
  • Responsible party and resident are to receive and sign Resident Outing into Community During COVID-19. 
  • During outings, resident and responsible party will agree to: 
    • Reading and understanding the COVID-19 Symptoms Education. 
    • Wear face coverings at all times
    • Practice social distancing
    • Limit interaction to the fewest number of people possible while resident is on leave
    • Love ones will limit their interactions to the fewest number of people possible for the two weeks before the resident’s planned leave/visit.
    • Responsible party will ensure resident washes hands before and after entering appointment/location. 
  • Residents will change clothing and wash hands upon return to the facility. 
  • Residents will be required to wear a mask and quarantine for 14 days post outing.
  • If facility cannot accommodate a quarantine room, the resident may need to transfer to another facility temporarily or stay with loved ones until a quarantine room becomes available.
  • Resident will be tested frequently during the 14 day quarantine to confirm negative status. 
  • Failure to wear a mask or quarantine may result in notice of discharge as they are a risk to the health of other residents. 
  • Facility to notify the local Ombudsman and public health agency regarding discharge for putting other residents at risk. 

Manage Visitor Access and Movement Within the Facility

  • Visits may be allowed depending on COVID status of facility. Refer to Visitation Guidelines in next section.
  • Non-essential workers will be allowed if there have been no COVID cases within 14 days (see Necessary Health Care Service Visits)
  • All visitors should perform frequent hand hygiene prior to entering unit and follow respiratory hygiene and cough etiquette precautions while in the facility, especially common areas.
  • Provide visitors education regarding COVID-19. (see COVID-19 Visitor Education)
  • Healthcare personnel and non-essential workers will be educated on infection control measures.
  • Visitors should not be present during AGPs or other specimen collection procedures.
  • Visitors should be instructed to only visit designated areas. They should not go to other locations in the facility.
  • In lieu of in-person visits, by preference or an outbreak, facility will provide ipads or tablets to allow residents an opportunity to have face-to-face interaction with family or friends.
    • Facility will assign a staff member to coordinated scheduled calls.
    • Tablet will be charged when not in use.
    • Tablets will not be shared between COVID positive and COVID negative residents.
    • Staff are to wear appropriate PPE when assisting resident.
    • If family member cannot be reached, document in the progress note and attempt to reschedule.
    • Tablet will be disinfected before and after each use.
      • Use a soft, lint-free cloth. Avoid abrasive cloths, towels or paper towels.
      • Do not use aerosol sprays, bleach, or abrasives. If using spray cleaner, do not spray directly on tablet.
      • May use 70% isopropyl alcohol wipes.
      • Avoid excessive wiping. Do not get moisture into any openings.
      • Unplug device with cleaning.

Visitation Guidelines

Royal Health Group facilities promotes person-centered visits while balancing the safety of all residents and staff. In-person visits may be restricted based on county positivity rates, the facility’s COVID-19 status, a resident’s COVID-19 status, visitor symptoms, lack of adherence to proper infection control practices, or other relevant factors related to the COVID-19 Public Health Emergency. Per CMS guidance, facilities will not restrict visits without a reasonable clinical and safety cause.

When appropriate, in-person visitation will be permissible in designated visitation spaces however, to reduce the risk and spread of infection, electronic methods for virtual communication between residents and visitors are preferred (Skype, FaceTime, WhatsApp or similar platforms). The following safety, care, and infection control measures must be adhered to for in-person visits:

  • A resident who is suspected or confirmed to be infected with COVID-19 is limited to receive visits that are virtual, through windows or in-person for compassionate care situations.
  • Prior to transporting a resident to the visitation space, the long-term care facility must screen the visitor for fever or respiratory symptoms. Any individuals with symptoms of COVID-19 infection (fever equal to or greater than 100.0 F, cough, shortness of breath, sore throat, myalgia, chills or new onset of loss of taste or smell) will not be permitted to visit with a resident.
  • Per Massachusetts Travel Ban, visitors from high-risk states must quarantine or have a negative test within 72 hours of arriving in Massachusetts. Visitors from bordering high-risk states are exempt from the testing requirement. Facility may request proof of negative testing for those traveling from non-bordering high-risk states. If visitor is unable to provide, facility administration to consult with local board of health or State Epidemiology for guidance. 
  •  Staff and residents must wear, at minimum, a surgical face mask and visitors must wear a face covering or mask for the duration of the visit. Facility may request visitor to wear mask, gown and gloves if necessary. Masks are located at facility entrance. 
  • Transport of a resident to and from the designated visitation space must be safe and orderly. At a minimum, safe transport means that the resident cannot be transported through any space designated as COVID-19 care space or space where residents suspected or confirmed to be infected with COVID-19 are present.
  • If HCP expect to provide direct care to residents while transporting the resident or monitoring the visitation, they must wear appropriate PPE in addition to mask and eye protection. 
  • Visitors must be limited to no more than two individuals.
  • Visitors will be provided education regarding COVID-19 and infection control measures. 
  • Items brought in for residents must be screened per policy prior to being brought into the facility, including preparer or deliverer to be free of symptoms. (See policy on Food)
  • Visitors and residents cannot share utensils or other dining/drinking equipment. 
  • The facility is not under a staffing contingency plan. 
  • A visitor must remain at least 6 feet from the resident and attending staff member(s) for majority of the visit.
  • Brief physical contact may be allowed if desired by both resident and visitor. In order to reduce risk of transmission, residents and visitors must: 
    • Use alcohol-based hand sanitizer with at least 60% alcohol before and after visit. 
    • Wear a mask at all times 
    • Limit the duration of close physical contact and avoid close face to face contact even with masks on 
    • Hug with faces in opposite direction 
  • The facility will clean the visitation space, including high-touch areas, before and after each visit using an appropriate EPA-registered disinfectant. 

For outdoor visits: 

  • Visits with a resident in a designated outdoor space with a covering for adverse weather must be scheduled in advance and are dependent on permissible weather conditions, availability of outdoor space, and sufficient staffing at the facility to meet resident care needs, and the health and well-being of the resident.
  • A long-term care facility staff member trained in such patient safety and infection control measures must remain immediately available to the resident at all times during the visit.

For indoor visits: 

  • Visits to occur a designated space that is as close to the entrance as possible where visits can be socially distanced from other residents and minimize impact in the facility. 
  • Ventilation systems, where applicable, will be serviced in accordance with manufacturer recommendations. Window may be opened for airflow. 
  • Avoid visitations in resident rooms unless the health status of residents prevents leaving the room and resident does not have a roommate. (See section on Compassionate Care Visits) 
  • Visitors will be limited to designated areas and will limit movement in the facility and will adhere to safety measures. 
  • A long-term care facility staff member trained in such patient safety and infection control measures must perform frequent safety checks with the resident during the visit.
  • There has been no new onset COVID-19 resident or staff cases on the unit, floor, or care area where the resident resides in the past 14 days and the facility is not currently conducting initial outbreak testing. 
  • Inside visits will be limited to Compassionate Care Visits if county positivity rates are over 10%. 
  • Indoor visits may be suspended if facility determines that a confirmed or suspected case within the facility poses a risk for all units.

Compassionate Care Visits: 

  • Compassionate care visits include but are not limited to: 
    • End of life visits
    • Newly admitted resident struggling with change in environment 
    •  Resident grieving after a friend or family member recently passed away 
    • Resident who needs cueing and encouragement with eating and drinking, previously provided by family and/or caregivers, and who is experiencing weight loss or dehydration. 
    • Resident, who used to talk and interact with others, is experiencing emotional distress, seldom speaking, or crying more frequently (when the resident had rarely cried in the past). 
  • Visits are to occur in designated indoor space or resident’s room if in a private room. 
  • Decisions about room visitation will be made on a case-by-case basis, and if appropriate in collaboration with the primary care provider or Medical Director. 

Family Education Visits 

  • Family members or caregivers may participate in discharge education and training when necessary to safely learn how to care for their loved one at home. 
  • Discharge education should only include necessary participants who must stay 6 feet away from resident and staff when not engaging in activities such as demonstrating resident transfers. 
  • Family members or caregivers will be screened and given appropriate PPE. 
  • Resident to wear mask at all times. 
  • Training will occur outside if permissible, in a designated indoor space or in therapy space provided no other residents or staff are present. 
  • Space, utilized equipment and high-touch areas will be disinfected using an EPA-registered disinfectant before and after training. 
  • Indoor and outdoor visits must be scheduled in advance. The facility may limit the length of any visit, but they may not be limited to less than 45 minutes if requested by resident or visitor. The days on which visits will be permitted must be no fewer than five days a week and one must be a weekend day. The facility may limit the hours during a day when visits will be permitted however, the facility must offer visitation times beyond standard business hours at least one day a week, Due to number of visits requests, facility may limit the number of times during the day or week a resident may be visited.
  • Any individual who enters the long-term care facility and develops signs and symptoms of COVID-19 such as fever, cough, shortness of breath, sore throat, myalgia, chills, or new onset loss of smell or taste within 2 days after exiting the long-term care facility or designated outdoor space must immediately notify the long-term care facility of the date they were in the facility, the individuals they were in contact with, and the locations within the facility they visited. Long-term care facilities should immediately screen the individuals who had contact with the visitor for the level of exposure and follow up with the facility’s medical director or resident’s care provider.
  • Whether or not a resident has visitors should not impact their access to fresh air and time outdoors. 
  • Residents have the right to access to the Ombudsman Program or Alliance and to consult legal counsel. If in-person visits are restricted due to infection control concerns, facility must coordinate telephonic or video communication. 
  • Any extensions of this timeline will be announced, and we reserve the right to modify at any point and may cancel visits for reasonable clinical or safety cause. 

Necessary Health Care Service Visits

Telemedicine is the preferred method of health care visits. An in-person visit will be allowed if necessary, based on the needs of the resident. 

  • Visits are limited to those considered essential to the health and wellbeing of the resident, and may include wound care, podiatry, dental, vision, audiology, behavioral health and hospice. 
  • Health Care Providers will be screen upon entrance to facility. 
  • Health Care Providers are to bring their own PPE into the building. Note- Other than mask, PPE cannot be worn into the facility. It must be donned upon entrance and cannot have been used in a previously visited facility. 
  • Health Care Providers will read and abide by Infection Control guidelines provided by facility. (See Necessary Health Care Services Guidelines)
  • Health Visits must be scheduled and coordinated with facility staff. Unscheduled visits will be prohibited. 
  • Health Services will be provided in resident room or designated area. 
  • If provided in designated area, only one resident is allowed in space at a time and all common areas and high touch areas must be disinfected between residents. 
  • If provided in room, curtain is to be closed and high touch areas disinfected after visit. 
  • Equipment must be disinfected between residents. 
  • Health Care Providers are to limit their visits to negative or recovered residents. 
  • Visits to Persons Under Investigation (Admissions) are allowed if medically necessary and benefit of treatment outweighs risk. 
  • Visits to Persons Under Investigation (Symptomatic) or Positive residents are to be postponed and re-assessed 14 days post symptoms or test with the exception of unmanageable pain requiring in-person visit from above-mentioned providers or end of life/ pending imminent death visits by hospice.
  • In the case of unmanageable pain or end of life/pending imminent death, visits are to take place with recovered, negative or asymptomatic residents prior to visiting symptomatic/positive residents and must follow facility PPE guidelines.
  • Seeing positive residents then negative residents on the same day is prohibited.

Non-essential Personnel Visits 

  • Non-essential personnel include, but are not limited to, the following individuals: barbers, hair stylists, volunteers, maintenance contractors and vendors performing cosmetic work (e.g. painting) as long as such work is not being performed in a resident’s room, and individuals working in facility gift shops.
  • Non-essential personnel should be licensed/certified in the State they are providing services, if applicable. 
  • Non-essential personnel are allowed to enter the facility provided the facility and personnel meet all safety, care and infection control measures:
    • There have been no positive resident or staff cases in past 14 days. 
    • The facility must have adequate supply of PPE and cleaning/disinfectant supplies to care for the residents.
    • The facility must not be under a contingency staffing plan due to staffing shortages, excluding use of agency staff. 
    • The facility continues to test employees per State guidance.
    • The long-term care facility screens all non-essential personnel for fever or respiratory symptoms before they enter the facility. The long-term care facility must not permit any individuals with symptoms of COVID-19 infection (fever equal to or greater than 100.0 F, cough, shortness of breath, sore throat, myalgia, chills or new onset of loss of taste or smell) to enter. 
    • Non-essential personnel must perform hand hygiene upon entering the facility, between residents, and before exiting the facility. 
    • Non-essential personnel must wear a face mask and eye protection for the duration of their time in the facility and don any other appropriate personal protective equipment.
    • Non-essential personnel must limit the surfaces touched and maintain six-foot distance from other people when possible. 
    • Facility will educate personnel regarding COVID-19 Infection Control Policy, transmission-based precautions, PPE and hand hygiene.
    • Facility representative will escort the personnel to area services/work is to be provided. 
    • When providing services in the long-term care facility, non-essential personnel must follow the same safety standards and checklists for any service they are providing outside the long-term care facility, including but not limited to, maintaining social distancing between residents, hygiene protocols, staffing and operations, and cleaning and disinfection. 
  • Hairdressers and barbers: 
    • Resident must wear a mask, as tolerated. 
    • Services will be limited to negative and recovered residents. 
    • Will be required to clean their work station, chairs, tables and high touch areas with an approved CDC disinfectant before and after each resident.
    • Appointments must be scheduled and coordinated with facility staff. Unscheduled visits will be prohibited. 
    • Services will be provided in resident room or designated area.
    • If provided in designated area, only one resident is allowed in space at a time. 
    • If provided in room, curtain is to be closed and high touch areas disinfected after visit. 
    • Equipment must be disinfected between residents. 
  • If volunteers are permitted in a long-term care facility, the following safety, care, and infection control measures should be implemented in addition to the measures described above: 
    • Volunteers must wear a face mask and eye protection for the duration of their time in the facility. 
    • Volunteers must remain socially distanced (6 feet apart) from residents at all times; and
    • Volunteers are not permitted to enter resident rooms or spaces designated by the facility for caring for COVID-19 positive residents. Volunteers are permitted in common spaces within the facility. 
  • Entrance to facility will be suspended if a resident or staff member tests positive for COVID-19. Entrance may resume when residents are in recovery and there are no positive resident or staff cases for 14 days and Board of Health or Epidemiology consents. 

Aerosol-Generating Procedures

Take Precautions When Performing Aerosol-Generating Procedures (AGPs)

  • Some procedures performed on patient with known or suspected COVID-19 could generate infectious aerosols. In particular, procedures that are likely to induce coughing (e.g., sputum induction, open suctioning of airways) should be performed cautiously and avoided if possible.
  • If performed, the following should occur:
    • HCP in the room should wear an N95 or higher-level respirator, eye protection, gloves, and a gown.
    • The number of HCP present during the procedure should be limited to only those essential for patient care and procedure support.
    • Visitors should not be present for the procedure.
    • Clean and disinfect room surfaces promptly as described in the section on environmental infection control below.

Collection of Diagnostic Respiratory Specimens

  • When collecting diagnostic respiratory specimens (e.g., anterior nares or nasopharyngeal swab), the following should occur:
    • Infection Control Preventionist will educate and confirm competency of licensed or un-licensed staff trained to perform specimen collection.
    • HCP in the room should wear an N-95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown.
    • The number of HCP present during the procedure should be limited to only those essential for patient care and procedure support.
    •  Visitors should not be present for specimen collection.
    • Specimen collection should be performed in a normal examination room with the door closed.
    • Clean and disinfect room surfaces promptly as described in the section on environmental infection control below.

Implement Environmental Infection Control

  • Dedicated medical equipment should be used when caring for patients with known or suspected COVID-19.
    • All non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected according to manufacturer’s instructions and facility policies.
  • Ensure that environmental cleaning and disinfection procedures are followed consistently and correctly. Increased frequency of high touch disinfecting to be done.
  • Routine cleaning and disinfection procedures are appropriate for SARS-CoV-2 in healthcare settings, including those patient-care areas in which aerosol-generating procedures are performed.
  • High touch areas are disinfected at least daily.
  • Management of laundry, food service utensils, and medical waste should also be performed in accordance with routine procedures.

Handwashing and Cleaning Supplies

  • Handwashing and disinfection are key strategies to reduce the risk of spreading the COVID-19 virus. 
  •  CDC recommends alcohol based sanitizer however hands must be washed with soap and water if visibly soiled or caring for residents with C-Difficile. 
  • Except when not appropriate on dementia units, alcohol-based wall units are located on the units. 
  • With wall units in short supply, personal bottles of alcohol-based sanitizer may be provided to each employee and kept with that person for their shift. Replacement bottles are available as needed. 
  • Housekeeping will use EPA registered hospital disinfectants or CDC acceptable alternate to disinfect units. Additional disinfection of high-touch areas will be conducted on COVID units and rooms. 
  • Disinfectants will be stored and secured away from residents however nursing and ancillary staff will have access in case cleaning or disinfection is needed after hours. 
  • Staff should immediately report supply needs to Executive Director or supervisor in his/her absence. 

Infection Control Line Listing

  • The Infection Preventionist will conduct ongoing surveillance for all Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections such as COVID-19 that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. (See Surveillance of Infections Policy)
  • The Infection Control Preventionist or Infection Control Lead, if different person, will maintain the infection control line listing for all residents and employees with respiratory or other infectious illnesses. 
  • Additionally, resident and employee symptoms, test results, and treatment are entered onto the Resident and Staff Tracking COVID-19 spreadsheet which is shared with regional support team. 
  • In the event of a resident outbreak, resident and employee cases are discussed daily with regional support team. 


Resident Care

The facility will take steps to minimize the number of staff interacting with residents to reduce the risk of transmission of COVID-19:

  • Clinical and ancillary staff will be dedicated to specific unit or wings and consistent assignments.
  • As much as possible, facility will make every effort to not float other staff to other floors. 
  • Facility will minimize the number of staff caring for each resident.
  • Facility will work with staff to limit onsite work to one facility whenever possible.
  • Facility will make every effort to have dedicated staff to care for positive residents. If unable, staff may be dedicated to positive and recovered residents. If available, assign a recovered staff member to assignment. 
  • Recovered residents may be on same assignment as positive, negative or quarantine residents. 
  • Certified Nursing Assistant assignments will be separated by positive and negative residents. 
  • Licensed nurse assignments will be separated by positive and negative residents. Facility to seek Epidemiology or BOH guidance when unable to separate licensed staff.
  • Facility will have designated activity aides and housekeeping staff for COVID units. 
  • If mixed unit, housekeeping will clean/disinfect rooms in this order- Non-COVID rooms, recovered, quarantine- new admission, negative but symptomatic rooms. Housekeeping staff will not reenter negative room after being in symptomatic or positive room.
  • Therapists will be dedicated to one building and will not see active COVID positive residents unless essential. Residents in recovery period may benefit from therapy and visits will be provided after visits with negative residents. 
  • During an outbreak:
    • Non-essential services will be postponed to limit the number of staff interacting with residents. 
    • Hospice visits will be limited to compassionate care for positive residents. If possible, aides will be dedicated to one building and dedicated to either positive or negative residents. All other visits will be completed via telemedicine. 
    • Therapy services will be limited to essential needs.
    • Facility will utilize telemedicine services for other services, I.E. Wound physicians, Behavioral Health Services and after-hours MD services. 

Staffing During a Pandemic

  • Facilities are to assess their staffing needs and the minimum number of staff needed to provide a safe work environment and patient care. 
  • Scheduler and DON meeting daily to review schedule and needs. Scheduler will plan staffing two weeks in advance. 
  • Communicate with local healthcare coalitions, federal, state, and local public health partners (e.g., public health emergency preparedness and response staff) to identify additional HCP. 
  • Coordinate agreements with temporary agencies in preparation of needs. 
  • Recruitment will seek candidates for the temporary nurse aide program.
  • Implement fast-track onboarding program to expedite credentialing and training of non-facility HCP: 
    • Human Resources to conduct background screens immediately upon position acceptance. 
    • Per State of Emergency, may utilize out of State licensees once approved from Massachusetts. 
    • Utilize abbreviated orientation (Agency Orientation) to onboard.
    • Facilities will offer the AHCA on-line classes and assign a certified nurse aide for the candidates to shadow and ensure competency. 
  • Plan to staff COVID-infected facilities: 
    • Facility current clinical staff will transfer to the COVID unit if appropriate.
    • Temporary aides, facility and regional, will cover non-COVID units with minimum of one certified aide on each floor. 
    • No daily floating between units will be allowed in COVID facilities, including activities, essential therapy, hospice and housekeeping. 
    • Medication and treatments to be reviewed, putting non-essential orders on hold for 30 days or reduce frequency of medication times in the event licensed staffing levels are reduced. 

Staffing Strategies

When staffing shortages are anticipated, RHG will use contingency capacity strategies to plan and prepare for mitigating this problem.

Contingency capacity strategies to mitigate staffing 

  • Adjusting staff schedules, hiring additional HCP, and rotating HCP to positions that support patient care activities. 
  • Cancel all non-essential procedures and visits.
  • Attempt to address social factors that might prevent HCP from reporting to work such as transportation or housing if HCP live with vulnerable individuals. 
  • Identify additional HCP to work in the facility. Be aware of state-specific emergency waivers or changes to licensure requirements or renewals for select categories of HCP. 
  • Postpone requests for vacation time during State of Emergency 
  • Prepare ancillary staff by having them take the ACHA eight-hour online nurse aide course. 
  • Contact retired or previously employed nurses or aides to offer temporary reemployment.
  • Medication and treatments to be reviewed, putting appropriate orders on hold for 30 days or reduce frequency of medication times in the event licensed staffing levels are reduced. 
  • Develop regional plans to identify designated healthcare facilities with adequate staffing to care for patients with COVID-19. 

   Crisis Capacity Strategies to Mitigate Staffing Shortages 
   When there are no longer enough staff to provide safe patient care: 

  • Implement regional plans to transfer patients with COVID-19 to designated healthcare facilities, with adequate staffing or close units after cohorting positive residents. 
  • ADL care should be limited to essential care only. Keep residents clean, dry & fed. 
  • Use ancillary staff to assist with hydration rounds, taking temperatures and passing out food trays 
  • Medication and treatments to be reviewed, putting appropriate orders on hold for 30 days or reduce frequency of medication times in the event licensed staffing levels are reduced. 
  • Speak with staff that are working from home and enlist their help for non-nursing duties.

Sick Leave Policy

  • Staff cannot work if they are experiencing symptoms consistent with COVID-19. They must cease work, notify their supervisor and be prioritized for testing.
  • Staff will not receive disciplinary action or poor job performance reviews because they take sick leave due to testing positive COVID. 
  • Staff are not required to provide a physician notes for a sick time related to COVID-19.
  • Staff will follow CDC guidance for staying at home without negative consequences.

Return to Work Policy

Asymptomatic Health Care Professionals (HCP) who have had an exposure to COVID-19 may continue working after the following conditions have been met:

  • They did not have prolonged close contact with confirmed individual. Prolonged close contact is being within 6 feet from the individual for more than 15 minutes in a 24-hour period.
  • If contact was prolonged, HCP wore the appropriate PPE.

If these conditions are met:

  • HCP must report temperature and absence of symptoms prior to starting work each day. Rhode Island exposed employees must monitor temperature every four hours while at work,
  • HCP must don a KN95 mask for the entire time that they are at work for the 14 days after the exposure event. Per policy, direct caregivers always wear mask and during resident care/interaction, wear eye protection.,
  • If HCP develops even mild symptoms consistent with COVID-19, they must cease patient care activities immediately and notify their supervisor prior to leaving work,
  • HCP is prohibited from working while they are symptomatic and, in accordance with DPH and DOH guidelines, must be tested for COVID-19.
  • HCP must remain out of work while awaiting COVID-19 test results,
  • HCP should avoid providing care for high risk patients, including immunocompromised patients, for the 14 days after the exposure event, and
  • Consider having HCP work shorter shifts (i.e. 8 hours) as there is early evidence that shorter shifts may be protective. 

Massachusetts guidance regarding employees who had prolonged exposure while not wearing PPE:

  • Employee to quarantine for 14 days, OR
    • Employee to quarantine for 10 days, provided the following are satisfied:
      • Employee has no symptoms;
      • Test negative using PCR test on or after day 8 of quarantine period;
      • Employee continues to monitor for symptoms for full 14 days. If symptoms develop, retest.
    • Quarantine period begins on first day isolated from confirmed case.
    • Exceptions to quarantine must be reviewed with epidemiology.

            COVID positive Health care personnel (HCP) may return to work in health care settings: 

  • Massachusetts

 Time-based strategy (remain out of work until): 

  • Not immunocompromised 
    • At least 72 hours have passedsince last fever without the use of fever-reducing medications and improvement in respiratory symptoms; and,  
    • At least 10 days have passed since test or symptoms first appeared
  • Immunocompromised
    • At least 72 hours have passedsince last fever without the use of fever-reducing medications and improvement in respiratory symptoms; and,
    • At least 20 days have passed since test or symptoms first appeared
  • Rhode Island*

Time-based strategy (remain out of work until):

  • Not immunocompromised 
    • At least 24 hours have passedsince last fever without the use of fever-reducing medications and improvement in respiratory symptoms; and,
    • At least 10 days have passed since test or symptoms first appeared
  •  Immunocompromised
    • At least 24 hours have passedsince last fever without the use of fever-reducing medications and improvement in respiratory symptoms; and
    • At least 20 days have passed since test or symptoms first appeared

Test-based strategy (remain out of work until):

  • Considered for severely immunocompromised and concerns exist for person being infectious for more than 20 days: 
    • Resolution of fever without the use of fever-reducing medications and
    • Improvement in symptoms, and
    • Two negative tests 24 hours apart 

*Rhode Island allows for positive, asymptomatic, health care staff to return to work sooner in limited circumstances. May only care for positive residents. See Infection Preventionist. 

If HCP was never tested for COVID-19 but has an alternate diagnosis (e.g., tested positive for influenza), criteria for return to work should be based on that diagnosis. 


Type of Tests 

Facilities may use POC antigen tests to complement the required State-level PCR testing. Antibody testing does not meet Federal or State requirements. 

Facility Staff Definition 

Similar to State definitions, facility staff include employees, consultants, contractors, volunteers and caregivers who provide care and services to residents on behalf of the facility. It also includes students in the facility’s nurse aide training program or from affiliated academic institutions. 

Testing Frequency

Facilities will follow Interim Testing Schedule which is more stringent that Federal and State guidance. (Subject to changes based on testing supplies and accessibility however will, at a minimum, meet State and Federal requirement).

Interim Testing Schedule:

  • Routine Testing
    • All employees testing one to twice weekly. If county positivity rates exceed 10%, test employees twice a week.
    • Admissions and readmissions to be tested on day 1, day 5, day 10 and day 14. Exception- COVID confirmed or less than 6 months recovered.
  • Outbreak Testing
    • All employees testing twice a week until 14 days with no new positive cases.
    • All residents to be tested twice weekly until 14 days with no new positive cases.
    • Testing includes residents and staff >3 months recovered who are exposed and symptomatic, OR > 6 months who are recovered and exposed.
    • Exception- employees and residents who are COVID confirmed.

Federal requirements for testing differ from State requirements. Refer to COVID Testing Massachusetts and COVID Testing Rhode Island testing grids for state-specific guidance. Facilities are to follow the most stringent guidance. There are three triggers for testing: 

  • Symptomatic Testing 
    • Federal- test any staff or residents who have signs or symptoms of COVID-19, including post 3-mos recovery staff and residents. Facilities must continue to screen all staff, residents and visitors.
    • State- test symptomatic staff or residents, including post 3-mos recovery and close contacts of the symptomatic staff or resident. 
    • Close contact is defined as being within 6 feet of someone who has COVID-19, for 15 or more minutes within a 24-hour period, while they were symptomatic or within the 48 hours before symptom onset or, if asymptomatic, the 48 hours before test was completed to the 10 days after the test was completed. 
  • Outbreak Testing 
    • Federal- test all staff and residents in response to an outbreak. Post 3-mos recovery residents and staff testing is encouraged but not required. An outbreak consists of a single new infection in staff or any nursing home onset infection in a resident. Staff and residents are to be tested every 3-7 days until no positive cases for 14 days, excluding staff not working during the testing period or residents on a leave of absence during testing period. 
    • State 
      • Massachusetts-
        • Test close contacts.
        • All residents on unit where confirmed employee worked or resident resides. 
        • Include residents and staff post 6-mos recovery who were exposed to confirmed case and post 3 mos recovery who were exposed and symptomatic
        • 100% of staff weekly until no positive cases for 14 days – NOTE- Federal inclusion of residents supersedes State guidance and therefore must be included.
      • Rhode Island- test all staff and residents weekly for 2 weeks. 
        • Close contact is defined as being within 6 feet of someone who has COVID-19, for 15 minutes or more in a 24-hour period, while they were symptomatic or within the 48 hours before symptom onset or, if asymptomatic, the 48 hours before test was completed to the 10 days after the test was completed. 
  • Routine Testing (Replaces Surveillance Testing) 
    • Federal 
      • Test all staff based on county positivity rates. 
      • Rates are posted weekly on CMS site and 
      • Facilities are to monitor rates weekly 
      • If county rates decrease to a lower level, facilities are to continue to test using higher level until rates remain at lower level for two weeks. 
      • If county rates increase to a higher level, facilities are to immediately adjust testing to higher frequency. 
      • Test residents who leave facility frequently. 
    • State 
      • Rhode Island-
        • weekly testing of all staff 
      • Massachusetts- testing based on county positivity rates 
        • 50% bi-weekly if <5% 
        • 100% bi-weekly if >5% 
        • Follow Federal frequency if county rates dictate more frequent testing than State. 
    • Staff and residents who have recovered and are asymptomatic do not have to be retested for COVID-19 within 3 months from date of onset of symptoms. Note- State guidance dictates 3 months from recovery whereas Federal dictates from onset. Use date from onset as marker.

 Federal Frequency Table 

Community COVID-19 Activity County Positivity Rate in past week Minimum Testing Frequency 
Low <5% Once per month 
Medium 5-10% Once per week* 
High >10% Twice a week* 

*Frequency presumes availability of POC testing on-site at the nursing home or where off-site testing turnaround is less than 48 hours. 

Testing Supply and Processing Availability 

Federal requirements dictate lab tests shall have a turnaround time of 48 hours or less. Should a facility not be able to meet these requirements, they must document efforts to acquire quicker turnarounds and contact the local and state health departments. This documentation to be maintained in COVID tracking log and/or COVID testing binder. 

Refusal of Tests 

  • Staff Refusal 
    • Staff who have signs and symptoms of COVID-19 and refuse testing are prohibited from entering the facility until the State-directed return to work criteria are met. 
    • If an outbreak occurs and staff member refuses to be tested, the staff member will be restricted from the building until the procedures for outbreaking testing have been completed. (Fourteen days with not positive cases). 
    • Unless medically or religiously exempt, routine testing is an expectation of all on-site employees. 
  • Resident Refusal 
    • Residents who have signs and symptoms of COVID-19 and refuse to be tested will be considered positive and placed on Transmission-based Precautions until criteria for discontinuation of TBP have been met. 
    • If an outbreak occurs and an asymptomatic resident refuses to be tested, the resident will be considered positive and placed on Transmission-based precautions until criteria for discontinuation of TBP have been met.

Documentation of Test Results 

  • Symptomatic testing
    • For residents and staff, document date(s) and time(s) signs and symptoms were identified, testing was conducted, results were obtained, and the actions taken by facility. Actions include, but not limited to, prompt implementation of COVID-19 Infection Control Measures (quarantine, cohorting, notification). 
    • Copies of lab results and required information will be documented on the COVID tracking log for residents and staff and the medical record for residents. Include and identify tests administered off-site. Copies of results will be also be maintained in a secured location.
  • Outbreak Testing 
    • Document the date the case was identified, the date all other residents and staff are tested, the date that all residents and staff who tested negative are retested, and the results of all tests.
    • Copies of lab results and required information will be documented on the COVID tracking log for residents and staff and the medical record for residents. Include and identify tests administered off-site. Copies of results will be also be maintained in a secured binder. 
  • Staff Routine Testing 
    • Document the facility’s county positivity rate and date rate was collected, the corresponding testing frequency, date staff were tested, and results of each test. 
    • Copies of lab results and required information will be documented on the COVID tracking log for residents and staff and the medical record for residents. Include and identify tests administered off-site. Copies of results will be also be maintained in a secured location. 

In medical record, document resident or staff refusal to test and how facility addressed the refusals. See section above regarding refusal of testing. 

Conducting Testing

  • The facility must obtain an order from a physician, physician assistant, nurse practitioner, or clinical nurse specialist to do resident testing of either PCR or antigen testing. Facilities may use standing orders. 
  • Facility medical director shall write an order allowing rapid POC tests to be performed on staff and other appropriate people. 
  • Facilities must have a current CLIA certificate appropriate for level of testing performed. 
  • Facilities are to follow manufacturer guidelines for testing. If provided, specimen collectors will participate in training and certification programs by the manufacturer of POC machines. 
  • The State of Massachusetts allows for unlicensed health care personnel to collect specimens if appropriately trained and supervised. The infection control preventionist or designee will serve as supervisor. 
  • During specimen collection, facilities must follow proper infection control and use proper PPE, which include N95 or higher, eye protection, gloves and gown. If N95 not available, a full face shield and KN95 or face mask may be used. Gloves to be changed after adding specimens to instrument. 
  • Facilities will decontaminate the instrument based on manufacturers recommendations. 

Reporting Testing 

  • Federal reporting 
    • CLIA testing- Antigen testing (done through State DPH or BOH) 
    • NHSN- weekly on Wednesday 
  • State reporting 
    • Rhode Island, in addition to Federal reporting: 
      • DOH- positive or symptomatic- immediately 
    • Massachusetts, in addition to Federal reporting: 
      • REDCap- positive cases or deaths within 24 hours 
      • CHIA- weekly by noon Friday 


  • The Executive Directors have been designated to communicate with staff, residents & families as the point person. This will include communication regarding confirmed cases of COVID -19 in staff and residents as well as PPE availability. 
  • New resident and employee cases will be sent to families via phone or text message blast by 5pm the following day. Updates will be made daily if changes, and weekly if no changes. 
  • Royal Health Group has a customer service line and the number has been made available to families and any messages are answered timely.
  • Communication may also take place on the Royal Health Group website as well as on our Facebook page.
  • Staff communication has been ongoing through blasts and videos through OnShift and the RHG TV. 
  • New resident and employee cases will be posted at the screening station. Posting will be updated daily with changes or weekly if there are no changes. 
  • Facilities will communicate new resident and staff cases to resident with verbal or written updates by 5pm the following day. 
  • Facility internal communication will be shared during morning meeting and may include:
    • New or revised policies
    • Any new cases since last meeting
    • Number of active COVID residents in house
    • Number of active COVID residents in the hospital
    • Number of residents in recovery and off isolation
    • PPE needs
    • Number of staff out due to COVID
    • Family or resident questions or concerns
    • Employee questions or concerns
  • Establish Reporting within and between Healthcare Facilities and to Public Health Authorities
    • Communicate and collaborate with public health authorities.
      • Designated representative within the healthcare facility will be responsible for communication with public health officials and dissemination of information to HCP.
    • The health department should be notified about residents with:
      • severe respiratory infection (inc COVID-19), or
      • a cluster (e.g., <3 residents or HCP with new-onset respiratory symptoms over 72 hours) of residents or HCP with symptoms of respiratory infections. (See “Influenza-Respiratory Illness Cluster Reporting 2019.pdf”).
    • Information will be communicated about known or suspected COVID-19 patients to appropriate personnel before transferring them to other departments in the facility (e.g., radiology) and to other healthcare facilities

Facility may deviate from policy to meet the facility specific needs as long State and Federal requirements are met.