Questions and Answers for Staff, Families, and Clients of Children's Residential Facilities: COVID-19
The Minnesota Department of Health (MDH) and Department of Human Services (DHS) are working together to monitor and respond to the developing COVID-19 situation. Together, the agencies recognize the immense value that Children’s Residential Facilities (CRFs) offer to children and families in our communities. Unfortunately, congregate settings such as these can result in rapid spread of COVID-19 among employees, clients, and their families. The questions and answers provided here are intended to help find ways to deliver services that minimize the risk of introduction and spread of COVID-19 within these settings. This guidance is intended to advise providers on best-practice recommendations and does not mandate specific actions.
As of 8/12/20
Carefully consider and, to the extent possible, redesign gatherings and activities to minimize disease transmission. MDH and DHS recognize that some best practices for reducing disease transmission may run counter to best practices for therapy and other essential components of a client’s treatment program or out of home placement plan. Incorporate disease mitigation strategies into daily programming and services as much as possible, and direct staff, visitors, and clients to follow the current statewide requirements which can be found at Minnesota COVID-19 Response.
The following are examples of general measures that facilities can take.
- Practice social distancing, especially when prolonged close contact (1) may occur, such as communal dining, medication administration, shared bathrooms, group therapy, or any group gathering. Where clients gather as a group, mark areas 6 feet apart to guide expectations around social distancing.
- Unless required for supervision, enter clients’ rooms as infrequently as possible to reduce potential for cross-contamination.
- Carefully consider reconfiguring gatherings of clients and staff to reduce close contact among staff, clients, and families. Consider holding gatherings or family visits outdoors.
- Stagger schedules for group activities (such as meals and recreation) to reduce the total number of people gathered at the same time.
- As much as possible, minimize close physical contact during family visits and therapy sessions. Consider use of electronic or virtual services or alternative locations (e.g., meeting outdoors as weather permits) to facilitate these therapeutic encounters.
- Add visual cues throughout the facility (e.g., signs or tape on the floor) to encourage frequent hand hygiene and reduce close contact.
- Consider arranging tables and chairs to be at least 6 feet apart.
- Wear masks or other appropriate protective equipment.
- Encourage families and clients to wear a cloth or disposable face covering for source control when in shared spaces or when close contact with other persons is likely to occur.
- To keep the risk of exposure low for staff, all staff should wear surgical face masks and eye protection (e.g., goggles or face shield) throughout their shift for all close contact encounters with clients. For encounters not involving prolonged close contact, staff can wear a cloth face covering for source control although cloth face coverings are not PPE. (2)
- Keep the environment clean.
- Direct staff to regularly clean and disinfect the facility, especially shared areas and frequently touched surfaces, using EPA-registered disinfectants more than once daily.
- Clean shared bathrooms at least twice daily and stock them with hand soap and paper towels or automated hand dryers.
- Keep the following items in common areas for everyone's use:
- Soap or alcohol-based hand sanitizers that contain at least 60% alcohol
- Trash baskets
- If possible, cloth face coverings that are washed or discarded after each use
- Further guidance can be found at COVID-19 Cleaning and Disinfecting Guidance for Schools and Child Care Programs.
- Prolonged close contact is defined as being within 6 feet of a person for greater than 15 minutes, or having unprotected direct contact with infectious secretions or excretions of another person
- Face masks are PPE and are often referred to as surgical masks or procedure masks. Use face masks according to product labeling and local, state, and federal requirements. FDA-cleared surgical masks are designed to protect against splashes and sprays and are prioritized for use when such exposures are anticipated, including surgical procedures. Face masks that are not regulated by FDA, such as some procedure masks, which are typically used for isolation purposes, may not provide protection against splashes and sprays. When available, face masks are preferred over cloth face coverings for staff as face masks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. Cloth face coverings should NOT be worn instead of a respirator or face mask if more than source control is needed.
Monitor clients at least daily for symptoms related to COVID-19 or any changes in their health status or behaviors. Common symptoms of COVID-19 include:
- Fever or chills
- Cough, shortness of breath, or difficulty breathing
- Muscle or body aches
- New loss of taste or smell
- Sore throat, congestion, or runny nose
- Nausea or vomiting
Additional information on symptoms can be found at CDC: Symptoms of Coronavirus.
Actively screen staff, visitors, and clients. Screen clients entering the facility as part of the new admission process and upon return from home visits. Ideally, the screening consists of taking the person's temperature and asking the following:
- Do you have signs or symptoms of a respiratory infection, such as a fever, cough, or difficulty breathing?
- Have you come into contact with someone who is suspected of having COVID-19 or who is currently ill with respiratory illness?
Templates of forms used for screening staff and symptom monitoring of clients can be adapted and used from forms found in the appendices of the COVID-19 Toolkit: Information for Long-term Care Facilities (PDF).
For visitors who have a measured or subjective fever (3), or who answer “yes” to any screening question, it is recommended that they be prohibited from entering the facility.
For clients who have a measured or subjective fever, or who have signs or symptoms of a respiratory infection, it is recommended they be quarantined per CDC: Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic. For clients who have had an exposure to a person who is suspected of having COVID-19, follow the CDC: Public Health Guidance for Community-Related Exposure and maintain a low threshold for testing if they have any change in health status. If your PPE supply allows, clients with exposures should be cared for using all recommended COVID-19 PPE until 14 days after last exposure. As testing resources allow, these clients should be prioritized for testing.
Staff who have a measured or subjective fever or who have signs or symptoms of a respiratory illness should not report to work. For further guidance. see “What if a staff member shows symptoms of illness?”. For staff who have had an exposure to a person in the community who is suspected of having COVID-19, also follow the CDC: Public Health Guidance for Community-Related Exposure. As testing resources allow, these staff members should also be prioritized for testing.
Encourage persons who meet screening criteria and enter the facility to wear a face covering, perform frequent hand hygiene, limit their interactions with others in the facility, avoid touching surfaces, and restrict their visit to the client's room or other location designated by the facility. If visiting family members have a disability or special health need that makes it difficult to wear a face covering, please see Best Practices for Masks: Considerations for People with Disabilities and Special Health Needs. Advise visitors to monitor themselves for signs and symptoms related to COVID-19 and to leave immediately if symptoms start to occur during their visit.
- Measured fever means a fever objectively measures by thermometer. Subjective fever means that the person feels warm or feverish.
If a client experiences possible symptoms of COVID-19, separate the sick client from the other clients to the extent possible. One option could be to designate an area to triage suspected and known positive cases. Designate staff for clients who are suspected or known cases. When clients are suspected of COVID-19 or become confirmed cases, notify family as soon as possible.
CRFs have potential for rapid spread of COVID-19 as they are congregate settings. Therefore, testing is recommended for all clients, staff, or family members who show symptoms or have close contact with a person with COVID-19 (4). While awaiting test results, encourage clients to stay in their room or at least 6 feet away from others in the facility. As testing resources allow, facilities with at least one positive case may consider broader testing of facility-wide staff and clients; however, testing alone should not replace robust mitigation and infection control strategies. Assist clients to coordinate COVID-19 testing with healthcare providers. The client's primary care physician may be able to provide COVID-19 testing or may need to refer the client to an alternative testing site. Clients, staff, or administrators having difficulty identifying a testing site can contact their local public health department or MDH to identify testing resources in their area.
Clients who test positive for COVID-19 will need to remain in isolation following the CDC criteria for discontinuation of isolation.
- Ideally, these clients should stay in a private bedroom with a private bathroom during their isolation period. If there are multiple clients who test positive, group them in the same shared bedroom if a private bedroom is not available for each. To avoid any unnecessary contact with ill persons, facilities may consider reducing cleaning frequency in bedrooms and bathrooms dedicated to persons with COVID-19 symptoms to as-needed cleaning (e.g., soiled items and surfaces).
- If it is necessary for a client who tests positive to be isolated in a bedroom with clients who have not tested positive, provide as much separation as possible among the roommates. Encourage the positive client and the roommates to wear a mask as much as possible; provide dedicated equipment/materials as needed; and increase cleaning frequency by staff, paying special attention to high-touch surfaces such as door handles and light switches. Avoid having clients with preexisting medical conditions share a bedroom with a client who has tested positive for COVID-19.
- If it is not possible to supply a private bathroom to client who has COVID-19 during their isolation period, clean and sanitize shared bathrooms after each use by the client.
If clients had prolonged close contact with persons with COVID-19 in the two days prior to those persons' symptom onset, follow CDC: Public Health Guidance for Community-Related Exposure. For staff, follow CDC: Interim U.S. Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to COVID-19.
It may be challenging to maintain social distancing for clients who test positive for COVID-19 or clients with high-level exposures, based on the client and setting. Modifications can be made to the client's Individual Program Plan (IPP), including their case plan, immediate needs plan, or resident treatment plan. The IPP needs to include specific methods and rationale for separating each client based on their particular situation.
If appropriate, encourage clients who have a suspected or positive case to wear a surgical face mask or cloth face covering when staff assist them with care. To keep the risk of exposure low for staff, all staff should wear surgical face masks and eye protection (e.g., goggles or face shield) when caring for symptomatic or COVID-19-positive clients. Gloves and gown may also be considered for situations in which contact with bodily fluids or secretions may be expected or encounters involving extensive body contact (e.g., toileting). Please note that face coverings may not be appropriate in all settings or for all persons. For more information on masking considerations for clients, see Masking Recommendations for Child Care and Schools: COVID-19.
For safe administration of nebulizer treatments to clients with suspected or confirmed COVID-19, facility staff can refer to Aerosol-Generating Procedures and Patients with Suspected or Confirmed COVID-19 (PDF).
Additional information on cleaning and disinfection for community facilities can be found at CDC: COVID-19 Guidance for Shared or Congregate Housing and CDC: Cleaning and Disinfection for Community Facilities.
To prevent the spread of COVID-19, it is crucial to monitor and take action when staff show symptoms. Staff members with symptoms should not report to work. Before the start of each shift, screen staff by checking temperature and assessing for symptoms related to COVID-19. If staff show symptoms during their shift, they should put on a mask (if not already masked), notify their supervisor, and leave work immediately to self-isolate at home. Ill staff should inform facility leadership about whom they were in contact, equipment used, and locations where they came in contact throughout their shift, as well as two days before onset of symptoms.
If staff are symptomatic, they should be evaluated by their primary care physician, who may recommend testing for COVID-19. Under no circumstances should staff be allowed to work while ill. If staff test positive for COVID-19, follow the CDC's symptom-based strategy to determine when these staff may return to work. Ask staff to self-monitor for symptoms and seek re-evaluation if symptoms recur or worsen. If staff test negative for COVID-19, or were not tested but have an alternative diagnosis, allow staff to return to work per the organization's standard guidance for ill employees, returning no earlier than 24 hours after fever resolution. For more information, visit CDC: Criteria for Return to Work for Healthcare Personnel with SARS-CoV-2 Infection (Interim Guidance).
Clients who have had prolonged, close contact with a positive health care provider (HCP) are considered to have been exposed, regardless of the level of PPE worn by the HCP or patient. To keep the risk of exposure low for staff, when caring for these clients it is recommended that staff wear a medical or surgical face mask, gloves, gown, and eye protection (goggles or face shield that covers all sides of your face) for 14 days following the last date of exposure to the positive HCP.
If your facility anticipates staffing shortages, please see guidance at CDC: Strategies to Mitigate Healthcare Personnel Staffing Shortages.
Screen new clients upon admission for fever and symptoms related to COVID-19. Facilities need to acknowledge that symptoms may be mild or absent in some people infected with COVID-19, particularly children and youth, but they still need to monitor closely for 14 days. Therefore, it is important to assess temperatures and symptoms daily in these clients. Testing for COVID-19 is recommended for clients who display any, even mild, symptoms of COVID-19 illness.
During the 14 days following admission to the facility, staff will need to work with each client to find ways to reduce possible spread of disease, especially when spread can occur prior to symptoms. If possible, assign new clients to a private room and bathroom, and take measures to maintain appropriate social distancing of these clients from the other clients.
MDH and DHS recognize that putting an adolescent into a separate environment could be damaging to the client and cause further distress, resulting in behavioral health issues. Staff need to be aware of the risks and provide appropriate supervision and support to clients. In some situations, separation may be not be possible due to developmental needs, behavioral concerns, or inability of staff to supervise. It is important to assess each client individually and make accommodations based on the client's individual needs, diagnosis, history, and comfort.
Appropriate infection control practices are key in preventing the spread of COVID-19. Educate newly admitted clients on symptoms of COVID-19, hand hygiene, respiratory etiquette, and the need to social distance in common areas. It is important that clients are aware and practice these infection control guidelines as best they can.
Family visits are essential to the well-being of clients within CRFs, yet they provide an opportunity for introduction of COVID-19 into the facility. Screen visitors for symptoms and potential COVID-19 exposures prior to entrance. A Visitor and Employee Health Screening Checklist is available in multiple languages at Businesses and Employers: COVID-19.
Request that visitors perform frequent hand hygiene, wear a face mask, limit interactions to the person they are visiting, and leave immediately if signs or symptoms arise during their visit. As resources allow, provide visitors with access to handwashing facilities, hand sanitizer, and face masks. Social distancing is ideal but will likely be a challenge for many because loved ones and clients will want to touch and interact closely with one another.
To ensure social distancing as much as possible within the meeting space, limit visitation to those who are considered essential in the client’s life and encourage a minimal number of visitors present at one time.. Whenever possible, hold visits outdoors or in a visiting room close to the facility entrance that can be easily cleaned and disinfected afterwards.
Remind clients and families to avoid touching their eyes, nose, and mouth, cover their cough, and practice good hand hygiene immediately before and after visits. When able, we encourage clients and families to wear a face mask during close interactions, but we understand this may not be possible in all situations because it may interfere with the visit. Consequently, specific recommendations should be made on a case-by-case basis. In general, face masks are not recommended for use by children under the age of 2, by persons who have trouble breathing, or who are unconscious, incapacitated, or otherwise unable to remove the mask without assistance.
To further reduce the risk of disease spread from asymptomatic visitors, encourage families who visit to practice strict social distancing when not at the facility and take precautions in the community while a loved one is in their care.
Fully explain the risk in advance of not cooperating with their infection control recommendations. If families do not cooperate, it is the facility’s decision to deny or allow a visit if a denied visit could have potentially negative consequences on the client.
If facilities allow uncooperative families to visit a client, it is recommended that these visits occur outdoors whenever possible. Provide these families with hand sanitizer and encourage frequent use. Remind clients and families not to touch their face, eyes, or nose and to practice hand hygiene after each visit. Facilities may want to increase client monitoring for symptoms related to COVID-19 to at least twice a day for two weeks following these visits.
Home visits are essential to plan the transition of services in the near future, but they could open an opportunity to introduce COVID-19 into the facility. Before allowing a client go on a home visit, assess any potential risks specific to the client, the home, and the persons living in the home. Discuss expectations with clients and family members.
It is recommended that facilities ask families to follow general infection control guidelines (e.g. hand hygiene, environmental cleaning) and adhere to the Governor's Stay Safe order for the general public. Ask families to limit in-home visits to immediate household members and other persons who are essential in the client's life.
Before the client returns to the facility, inquire about the client’s health status and any known COVID-19 exposure during the home visit.
- When a client did not have known exposure to COVID-19, continue to monitor for symptoms and follow your policy for new admissions.
- If you suspect a community-related exposure (CDC: Public Health Guidance for Community-Related Exposure) to a COVID-positive person, the client should begin a 14-day quarantine period to monitor for symptoms and prevent further transmission. Consider the following when deciding the most suitable setting for quarantine:
- Specifics of the exposure
- The home and facility environments
- The client's individual behavioral and therapeutic needs
- The family's needs, and the facility's needs, including the need to protect the safety of other staff and clients. Involve others including case managers as needed or required.
- Testing should also be considered in situations when close exposure to a person with known COVID-19 has occurred. However, due to testing limitations, a 14-day quarantine period is still recommended regardless if the individual seeks testing and tests negative.
- If the client is quarantined at the facility, separate them if possible from others or group them with other clients who may also have had community exposures.
MDH and DHS recommend that, to the extent possible, facilities:
- Use the largest vehicle(s) available.
- Limit the number of passengers on each trip to increase distance between driver and passengers.
- Encourage mask-wearing and social distancing during transport.
- Encourage hand hygiene before and after transport (and during with the use of alcohol-based hand sanitizer).
- Remind drivers and passengers to avoid touching their face during transport (consider posting signage in the vehicle as a reminder).
- Improve ventilation by opening windows or setting air conditioner to non-circulation mode; and clean and disinfect the vehicle after each use.
The following resources provide additional guidance:
Staying active is an important way to support clients’ physical and emotional health. However, accessing community activities also creates opportunity for introducing COVID-19 to the facility. In addition to following general guidelines for the public such as the Executive Orders from Governor Walz, MDH and DHS recommend that the following be considered when selecting discretionary recreational and community-based activities:
- Will social distancing be practicable given the space, activities, and any other persons involved?
- Does the place you are visiting share, post, or announce that they have increased cleaning and disinfection to protect others from COVID-19?
- Will participants have access to handwashing facilities?
- Are participants able to practice respiratory and other infection control etiquette to minimize risk to others?
Bring supplies such as disinfectant wipes, face masks or cloth face covering, and hand sanitizer on outings. Consider bringing additional PPE as necessary and available for situations that require close prolonged contact or if contact with infectious secretions or excretions is anticipated (e.g., toileting assistance).
Use single-serving food and beverage options during outings, or identify one person to serve or dispense sharable items, so multiple people are not handling the items. Wear gloves when handling trash.
CDC guidance on Errands and Going Out contains additional guidance that may be helpful in making decisions about outings and recreation.
Despite best efforts to practice social distancing, there may be occasions when staff members need to physically intervene with a client to protect the health and safety of the client or others. These situations are particularly challenging because they can arise with little to no warning. MDH and DHS recommend the following to reduce the risk of COVID-19 transmission associated with these interactions:
- Review techniques for avoiding restrictive procedures including relationship building, de-escalation techniques, avoiding power struggles, etc.
- Wear appropriate PPE:
- For physical contact with persons who are not known or suspected to have COVID-19 and who have not had a known exposure in the past 14 days, wear a surgical mask and eye protection.
- For physical contact with persons who have confirmed or suspected COVID-19, or have had a known exposure in the past 14 days, wear gloves, gown or coveralls, N95 (or higher) level respirator (surgical face masks are an acceptable alternative if respirators are not available), and eye protection such as goggles or face shield that fully covers the front and sides of the face.
- Clean and disinfect any equipment or belongings that may be contaminated after any close physical contact with a client who has confirmed or suspected COVID-19, with an EPA-registered household cleaning spray or wipe, according to the product label; contain and dispose of used PPE, and launder any clothing that may be contaminated (avoid shaking the clothes). Follow existing protocols for exposure to bodily fluids.
- Store necessary PPE in various locations throughout the facility so it is readily available in the event it is needed for an escort or restraint, and ensure that staff persons know where it is located.
Considerations are based on the client's status:
- Clients without symptoms and no known exposure to COVID-19: Recommend to the client and their parent/guardian that they monitor for symptoms for 14 days after discharge from the facility, regardless if they receive negative test results. The discharging facility should ask the receiving facility or family to inform the discharge facility if the client becomes symptomatic or tests positive. This will help facilitate timely identification of persons who may have been exposed.
- Clients without symptoms and a known exposure to COVID-19: Discharge to a location where they can safely remain separate from others and be monitored for symptoms for 14 days from the date of last exposure, regardless if they receive negative test results. If discharge involves another congregate setting, MDH recommends that the receiving location monitor the client for symptoms for 14 days from date of transfer, and that staff use all appropriate PPE (as available) when providing direct care. The receiving location should take additional steps to reduce possible spread of disease. This could include social distancing of greater than 6 feet, working with clients to promote hand hygiene, assigning a dedicated bathroom if possible, and increasing environmental cleaning of any shared areas where the client is spending time.
- Clients with symptoms and negative COVID-19 test result: Postpone discharge until symptoms have improved and they have been fever free for 24 hours without fever reducing medications.
- Clients with symptoms and positive COVID-19 test result: Postpone discharge until at least 10 days have passed since their symptoms started, including 24 hours fever free without fever reducing medications, and symptoms are improving.
A person who has clinically recovered from COVID-19 and then is identified as a contact of a new case within 3 months of symptom onset of their most recent illness does not need to be quarantined or retested for SARS-CoV-2. However, if a person is identified as a contact of a new case 3 months or more after symptom onset, they should follow quarantine recommendations for contacts.
For more information see CDC: Duration of Isolation and Precautions for Adults with COVID-19.
Regular education and discussion groups related to COVID-19 may help clients and families understand, correct misinformation, and cope with the virus and its impacts. Try to keep discussions simple and actively engaged. If possible, get creative and educate with activities and visuals, or reward clients who apply this information.
Resources to help children understand and discuss COVID-19:
- CDC: Talking with children about Coronavirus Disease 2019
- NSTSN: Trinka and Sam Fighting the Big Virus: Trink, Sam, and Littletown Work Together
Some topics and discussions could include:
- Healthy habits like washing hands, covering your cough
- How to appropriately wash your hands
- Activity: Put glitter on their hands and see how long it takes for them to wash it off.
- CDC: When and How to Wash Your Hands
- How COVID-19 spreads
- How to stay in control over the risk of infection
- How to manage separation and grief related to COVID-19
- The importance of wearing a mask and types
- Physical Activity with other children
- COVID-19 symptoms
- Symptoms vary from person to person; some experience no symptoms while others experience severe symptoms
- People can still spread COVID-19 without any symptoms
- Social distancing
- Ways to stay connected without physical contact
- COVID-19 Prevention Guidance for Youth, Student, and Child Care Programs (PDF)
- CDC: Cleaning and Disinfecting Your Facility
- CDC: COVID-19 Guidance for Shared or Congregate Housing
- CDC: Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings
- CMS: Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IIDs) and Psychiatric Residential Treatment Facilities (PRTFs) (PDF)
- COVID-19 Cleaning and Disinfecting Guidance for Schools and Child Care Programs
- COVID-19 Toolkit: Information for Long-Term Care Facilities (PDF)
- Evaluating and Testing: COVID-19
- COVID-19 Prevention Guidance for Youth, Student, and Child Care Programs (PDF)
- Interim Guidance on Facemasks as a Source Control Measure (PDF)
- Masking Recommendations for Child Care and Schools: COVID-19
- The Difference between Alternative Masks and Surgical Masks for COVID-19 (PDF)
- Playground Guidance for Schools and Child Care Programs (PDF)