Introduction
The recent spread of the coronavirus around the world is justifying significant concern among senior living operators and raising questions about how to prepare for and respond to the possibility that the disease will affect residents, staff, and visitors. This concern is exacerbated by the fact that seniors tend to be more vulnerable to such communicable diseases and live in close quarters with others at the community, sharing meals and participating in group activities.
This article will suggest various strategies that can be implemented to reduce the risk of contagion, identify individuals who may have been exposed to the disease, and minimize the risk of contagion among residents, staff, family members, and other visitors.
Current State of Understanding About the Disease
COVID-19, commonly referred to as the coronavirus, is a novel disease that is causing viral respiratory illnesses around the world through person-to-person transmission. Current data indicates that the virus is mainly transmitted through close contact (approximately within six feet) with an infected person, often via exposure to respiratory droplets that are produced when the infected person coughs or sneezes.1 It is also possible for an individual to become infected by touching a surface or object that has the virus and then touching one’s mouth, nose, or eyes.2
As of the date of this article, coronavirus cases have been reported in over 40 countries, with the majority of them concentrated in China, where the first case originated. Coronavirus currently is not spreading in communities in the United States. However, top health experts at the Center for Disease Control and Prevention (CDC) have warned that an outbreak in the U.S. is not a matter of “if,” but is more a question of “when.”3 The CDC maintains an ongoing count of confirmed cases of the coronavirus in the U.S. on its website.4
Although some spread is possible before symptoms manifest, infected individuals are thought to be most contagious when they are symptomatic.5 A complete clinical profile of the COVID-19 is under development, but CDC believes at this time that the incubation period of this coronavirus can range from 2-14 days.6 Commonly reported symptoms include fever, cough, and shortness of breath.7 More severe cases can result in pneumonia. Seniors and individuals with preexisting medical conditions, such as diabetes, are at a heightened risk of developing severe complications. The fatality rate of the coronavirus is still being analyzed, but according to a February 24, 2020 paper released by the Journal of the American Medical Association that studied recorded cases from mainland China as of February 11, 2020, the average fatality rate is 2.3%, but rises to 8% in patients between the ages 70-79 and 14.8% in patients over 80.8 Currently, there is no vaccine against COVID-19.
Initial Precautions That Can Be Taken to Reduce the Risk of Contagion
Given the highly transmissible nature of the coronavirus and the limited treatment options available in severe cases, prevention should be a senior living community’s first line of defense. Education and training of staff, residents, visitors, and volunteers is essential. Among the topics to be discussed, and best practices to be implemented, are:
- Hand hygiene (frequent washing, use of gloves, and use of hand sanitizers).
- Respiratory hygiene/cough and sneeze etiquette (use of disposable tissues or elbow when tissues unavailable, use of facemasks).
- Environmental cleaning (wiping down surfaces with antibacterial/virucide cleansers. Clean frequently touched areas, such as doorknobs. Provide disposable wipes for commonly used surfaces).
- Observing waste disposal best practices (e.g. touchless, lined wastebaskets).
- Reminder trainings of staff and volunteers on sources of exposure, prevention, recognition of symptoms, response when an outbreak has been identified, and communication protocols.
- Education of residents and visitors about prevention practices, response, and precautions implemented at the community.
- Post educational materials about the coronavirus and that explain why infection control precautions are necessary.
- Post signs notifying residents, staff, and visitors to report any experienced respiratory symptoms to management.
- Consider implementing protocols for staff travel (leisure or work-related), including international travel to countries with confirmed cases of the coronavirus.
- Assess status of the community's preparedness (stockpiling supplies such as sanitizer, masks, gloves, cleaning products, water, food, and linens).
In terms of easily-adoptable, community-wide initiatives, senior living operators should consider making hand sanitizers, including automatic dispensers, with at least 60% alcohol content readily available to residents, staff, and visitors, especially at entrances to assembly areas.
Additional coronavirus-specific prevention guidance and print literature are available on the CDC’s website9, and for communities with skilled nursing facilities, the World Health Organization’s “The COVID-19 Risk Communication Package for Healthcare Facilities” toolkit contains flyers that may be instructive as well.10
Attention to, and increased focus upon, standard hygiene practices in a community can be effective in reducing the risk of exposure to, and the spread of, any contagious disease. The experience of senior living communities with diseases such as the Norovirus and common influenza can be applied to help mitigate coronavirus risk.
General precautions against the spread of infectious diseases should be more rigorously observed during this time, even if there is no suspicion of the coronavirus being present. For example, employees who are not feeling well should be instructed to stay at home and not potentially expose residents and coworkers to infection. A community might want to implement or evaluate for flexibility its policies regarding telecommuting as appropriate depending on job function, especially for staff who have traveled internationally. Similarly, if a community contracts with a staffing agency and/or provides lists of approved staffing agencies to residents for private duty aid assistance, the community might inquire about and consider the precautions and protocols that the staffing agencies have regarding vetting individuals for contamination and education on self-assessing and reporting symptoms.
Identification of Individuals Who Have Been Exposed to the Virus
At this point, there is no reliable way to distinguish coronavirus symptoms from symptoms caused by the common flu, as both diseases can cause fever, coughs, and pneumonia in severe cases.11 Leading medical professionals, including those from the Yale School of Medicine, agree that as of mid-February 2020, the flu has a much larger impact on Americans than the coronavirus, with at least 15 million flu cases reported this season.12 Communities should take care to not over-attribute symptoms shared with the flu to the coronavirus.
One of the greatest difficulties with this disease is that an individual may have been exposed to it and not exhibit any outward symptoms for a period of up to approximately two weeks. Therefore, it is difficult to identify a person who may be a carrier of the coronavirus by mere observation alone.
Senior living communities may begin their precautionary measures by first surveying their residents and staff to determine if they have traveled within the last 30 days to countries with heightened Department of State and CDC warnings.13 These travel advisories are evolving day by day, but as of February 26, 2020, the CDC recommends avoiding nonessential travel to China and South Korea. It also recommends practicing enhanced precautions in Italy, Japan, and Iran.
Staff who have traveled to the aforementioned countries within the last 30 days should be encouraged to work remotely when possible. Residents who have traveled to the aforementioned countries should be assessed in accordance with CDC risk assessment guidelines for persons with potential exposure to COVID-19, available at: www.cdc.gov/coronavirus/2019-ncov/php/risk-assessment.html
As the disease becomes more widespread, in addition to travel questions, managers may also ask generally if, in the past 30 days, residents or staff have been exposed to any person or place where the coronavirus is known to have been present.
If a staff person or visitor exhibits symptoms associated with the coronavirus, the community should disallow nonessential visits from that individual until symptoms have resolved.
If a resident exhibits symptoms associated with the coronavirus, the community should take the following steps:
- Immediately contact the resident’s primary care physician and, if applicable, notify the resident’s family as soon as practicable;
- Obtain a detailed 30-day travel and potential exposure history from the resident; and
- Request that the physician makes a clinical assessment in accordance with CDC guidelines for “Evaluating and Reporting Persons Under Investigation (PUI)” to determine whether the resident meets the criteria for evaluation for COVID-19. The PUI guidelines are available at: www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-criteria.html
If the resident does not meet the PUI criteria for follow-up testing, the community and the resident’s physician should monitor the resident in accordance with standard communicable disease procedures. If the resident does meet the PUI criteria, the community should coordinate with the resident’s physician to contact state or local health departments immediately and implement community-wide infection control best practices.
As of the date of this article, the Food and Drug Administration, under its Emergency Use Authorization, has approved one CDC diagnostic panel for detection and/or diagnosis of COVID-19. However, testing is currently limited to qualified laboratories designated by CDC and certified to perform high complexity tests.14 Laboratory testing likely will become more widely available in the near future.
Response to the Presence of Carriers on the Premises
If a suspected carrier of the coronavirus has been identified on the premises of the community, that person should be isolated as soon as possible and should remain isolated until the aforementioned CDC PUI evaluation process is complete. If a confirmed carrier is a resident, the community should prevent other residents from congregating in common areas and limit group activities and visitors until after the scope of possible exposures to others has been assessed. Residents who may have been exposed through interactions with the carrier should be monitored based on the aforementioned CDC risk assessment guidelines. If there are quarantine or special treatment facilities available in the area, the community manager should consider moving the carrier resident to those facilities. For licensed properties, an individualized care plan should be developed and implemented for each affected resident.
If the carrier is an employee, he or she should be kept off the premises until the illness has resolved itself. Staff interacting with an infected resident should use face masks, gloves, and protective clothing. To help reduce the risk of contagion, staff should not be rotated to different parts of the building. Cross training to perform duties becomes essential in the event of an outbreak.
Some effort should be made to determine whether the carrier is likely to have contracted the illness from an outside source (e.g., travel to an area with a high concentration of the virus, off-site proximity to a known carrier) or whether the disease might have been contracted from another resident or staff person on the premises.
Additionally, confirmed cases of coronavirus should be reported to applicable licensing agencies as soon as practicable. It may be prudent to post signage in areas where infected residents have been placed in isolation and/or to provide written notification to vendors and other visitors. In the event of an outbreak of the disease, it may become necessary to limit the admission of new residents.
Privacy and Discrimination Issues
Whenever it becomes necessary to communicate to others that an individual resident or staff member is infected with the coronavirus, the senior living operator must be careful not to breach the privacy rights of the individual. For example, if there are areas where an infected person is being held in isolation, the manager should be careful not to identify the person, wherever possible. For those communities subject to HIPAA, the law allows disclosure of limited information to residents' family members and other individuals involved in residents' care, provided residents are given an opportunity to object to such disclosure. The law also allows disclosure to health oversight agencies and authorities. Social media disclosures by staff are not permitted. If an outbreak occurs, the media likely will make inquiries and in that case the community should proceed very cautiously. Per HIPAA, the community may not volunteer information, but if the media asks for the resident by name, then the community may, but is not required to, provide very limited information in accordance with the HIPAA rules.
Although disability discrimination laws in general require "reasonable accommodation" of a person with a disability, there is an exception when the disability constitutes a "direct threat" to the health and safety of others. Practices such as quarantine or isolation, restriction of visitors, and inquiries concerning potential exposure to the coronavirus should be acceptable as reasonable efforts to prevent or mitigate the risk of infection of other residents, staff, and visitors at the senior living community.
Additional Resources for Monitoring COVID-19 and Recommended Responses
CDC guidance for confirmed or suspected coronavirus infection:
Occupational Safety and Health Administration (OSHA) guidelines on coronavirus control and prevention for employees: www.osha.gov/SLTC/covid-19/controlprevention.html#health
Source for monitoring breaking news and developments regarding the virus: The New York Times coronavirus page, at www.nytimes.com/2020/02/25/health/coronavirus-us.html
We also recommend that communities monitor their state Department of Public Health websites for more regional and local guidance. Many states are currently building out their resources and/or are linking to the CDC website. Examples include:
This alert was prepared in coordination with the American Seniors Housing Association.
1 “How COVID-19 Spreads” by the CDC, at www.cdc.gov/coronavirus/2019-ncov/about/transmission.html
2 Id.
3 Pam Belluck and Noah Weiland, “C.D.C. Officials Warn of Coronavirus Outbreaks in the U.S.” The New York Times, at www.nytimes.com/2020/02/25/health/coronavirus-us.html
4 “Coronavirus Disease 2019 (COVID-19) in the U.S.” by the CDC, at www.cdc.gov/coronavirus/2019-ncov/cases-in-us.html
5 “How COVID-19 Spreads” by the CDC, at www.cdc.gov/coronavirus/2019-ncov/about/transmission.html
6 “Healthcare Professionals: Frequently Asked Questions and Answers” by the CDC, at www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html
7 “What you need to know about coronavirus disease 2019 (COVID-19)” by the CDC, at www.cdc.gov/coronavirus/2019-ncov/downloads/2019-ncov-factsheet.pdf
8 Zunyou Wu and Jennifer M. McGoogan, “Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China,” February 24, 2020, at jamanetwork.com/journals/jama/fullarticle/2762130
9 “Prevention & Treatment” by the CDC, at www.cdc.gov/coronavirus/2019-ncov/about/prevention-treatment.html
10 “The COVID-19 Risk Communication Package For Healthcare Facilities” by the World Health Organization, downloadable at iris.wpro.who.int/bitstream/handle/10665.1/14482/COVID-19-022020.pdf
11 “Coronavirus Disease 2019 vs. the Flu,” at www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-disease-2019-vs-the-flu
12 “Influenza (Flu) vs. Coronaviruses,” at www.ynhhs.org/patient-care/urgent-care/flu-or-coronavirus
13 CDC Travel Health Notices, at wwwnc.cdc.gov/travel/notices
14 FDA Emergency Use Authorizations, at www.fda.gov/medical-devices/emergency-situations-medical-devices/emergency-use-authorizations
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