Residential Substance Use Disorder Treatment Facilities: COVID-19 Frequently Asked Questions
Congregate living settings, including residential substance use disorder treatment (SUD) settings, can contribute to rapid spread of COVID-19 among staff members, clients, and others who have close contact with clients. In addition, some clients who reside in SUD facilities frequently spend time in the community, which increases the opportunity for the introduction of COVID-19 into the facility. This guidance supplements other recommendations for SUD facilities. Outside of these recommendations, SUD providers need to stay updated on current state and federal requirements. This guidance is intended to advise providers on best-practice recommendations and does not mandate specific actions, except where measures are part of state or federal requirements.
Staff, visitors, persons who use services, and administrators of substance abuse facilities must stay in compliance with statewide requirements, including the requirement that face coverings be worn in indoor businesses and indoor public spaces. More information on current statewide requirements can be found at Minnesota COVID-19 Response.
The statewide requirement to wear face coverings applies inside substance abuse treatment facilities, except that clients and visitors are not required to wear face coverings when in a client's assigned room/living unit unless required to by facility policy. More information about statewide face covering requirements can be found at Protect Yourself and Others: COVID-19.
In addition to statewide requirements, the following practices continue to be recommended to minimize the risk of disease transmission in congregate settings:
- Maintain social distancing (i.e., maintain physical distance of 6 feet or more between individuals).
- Wear face coverings to prevent spread of respiratory secretions even when not otherwise required.
- Frequent hand hygiene.
- Daily screening of clients, staff, and visitors for signs of infection. In addition, all staff should wear surgical facemasks and eye protection (e.g., goggles or face shield) throughout their shifts for all encounters longer than 15 minutes and within 6 feet of clients to keep the risk of exposure low for staff and to prevent potential spread of COVID-19 from infected individuals who may not have symptoms. Additional considerations for SUD facilities must be tailored to the specific situations that occur in these settings.
Admission and readmission:
- Screen new admissions for fever and symptoms related to COVID-19.
- Consider a 14-day pre- or post-admission quarantine of new admissions. In lieu of a quarantine, assign new clients to a private room and bathroom, if possible, and take measures to maintain appropriate social distancing of these clients from other clients. Encourage these clients to use a face covering at all times when not in their room.
- Newly admitted or readmitted clients should be monitored for fever or other symptoms of COVID-19 for 14 days after admission and cared for using all recommended personal protective equipment (PPE), such as surgical facemasks or respirators, eye protection, gloves, and gown. Cloth face coverings are not considered PPE.
- Testing for COVID-19 is recommended for clients who display any, even mild, symptoms of COVID-19 illness or have a close exposure to someone with COVID-19. See more about testing asymptomatic people at Evaluating and Testing: COVID-19.
- Educate newly admitted clients about COVID-19 symptoms and what to watch for, noting that some people can have the disease without any symptoms. Inform them of the importance of hand hygiene, respiratory etiquette, and the need to social distance in common areas.
For more information on recommendations for admissions, see Interim Guidance for Discharge to Home or New/Re-Admission to Congregate Living Settings and Discontinuing Transmission-Based Precautions (PDF).
Group therapy and group education:
- Use telehealth to the extent possible to minimize face-to-face interactions, limit group sizes, and provide service continuity to clients who must isolate or quarantine during the course of their treatment.
- Limit indoor group sizes. Strategies to achieve these limitations may include use of telehealth, holding smaller groups with staggered schedules, or using space differently.
- Clients and staff must wear face coverings consistent with statewide requirements and practice social distancing during group meetings. Consider rearranging furniture, using tape or other visual cues to mark safe distances, and posting signage to reinforce these practices. COVID-19 prevention signage is available at Materials and Resources for COVID-19 Response and CDC: Print Resources.
- Advise hand hygiene prior to attending in-person groups and have hand sanitizer readily available throughout the session.
- As much as possible, eliminate the use of shared supplies and equipment. Once equipment is used by a staff person or client, set it aside immediately for cleaning or laundering.
- Clean and sanitize high-touch surfaces on a frequent basis using EPA-registered products. For more information, visit CDC: Cleaning and Disinfecting and CDC: Cleaning and Disinfecting Your Facility.
Accessing health care during treatment:
- Encourage clients to use telehealth services whenever possible to minimize potential exposure to COVID-19 in community health care settings.
- Encourage clients to perform frequent hand hygiene, wear a cloth face covering, limit interactions to the practitioner(s) whom they are visiting, and to practice social distancing. As resources allow, provide clients with hand sanitizer and a cloth face covering they can take with them to their appointments. Remind clients to avoid touching their eyes, nose, and mouth; cover their cough; and practice good hand hygiene immediately before and after visits.
Situations in which exposure cannot be ruled out:
Clients may engage in activities (e.g., visiting friends or family, attending work, or attending community events) where exposure is possible due to the current level of community transmission in Minnesota. Therefore, it is important to encourage all clients and staff to self-monitor for symptoms and to report signs and symptoms of illness immediately; maintain physical distance from others; and wear a face covering if not medically contraindicated. Additional steps may be needed when the person returns, to ensure other clients and staff remain safe. Educate clients, visitors, and staff who are leaving the facility on ways to further reduce the risk of disease transmission once they return to the facility.
When a client has had close contact with known cases, consider taking the following steps to further reduce the risk of disease transmission:
- Place the client in a private room, if possible. If a private room is not available, make decisions about room assignments on a case-by-case basis, considering infection risks to other clients in the room and available alternatives.
- Serve meals to the client in a private room or in common areas, at least 6 feet away from others.
- Have a dedicated bathroom for the client, or clean and sanitize the bathroom after each use.
- Require the client to wear a face covering when in communal areas, consistent with statewide face covering requirements, and to cover their coughs and sneezes. Per Executive Order 20-81 (PDF), residential treatment facilities may also require clients to wear a face covering within living areas.
- Have staff and clients perform frequent hand hygiene.
- Ensure staff are properly trained to use and wear PPE appropriately.
- As resources allow, reverse transcription polymerase chain reaction (RT-PCR) testing may be useful to identify clients who are infected with COVID-19. However, it is possible for a person in the early stages of COVID-19 infection to have negative RT-PCR results. For this reason, a negative RT-PCR test does not rule out COVID-19 infection and the precautions described above are still recommended.
It is important to also note that clients who have had prolonged, close contact with a health care provider (HCP) who has tested positive for COVID-19 are considered to have been exposed, regardless of the level of PPE worn by the HCP or client. Since COVID-19 could develop within 14 days of an exposure event, the risk of disease transmission following activities for which exposure cannot be ruled out is also 14 days. Use CDC: Public Health Guidance for Community-Related Exposure to assess the risk to a client exposed to an HCP with COVID-19.
Clients retain their rights to access the community, unless otherwise restricted due to the individual's legal status, treatment needs, or public health quarantine recommendations. Educate clients that spending time in the community may increase their risk of COVID-19 exposure, which in turn impacts the risk to other facility clients, staff, and visitors. More information can be found at CDC Coronavirus Disease 2019 (COVID-19): Deciding to Go Out.
Encourage clients to practice social distancing; wear a face covering when they cannot maintain social distancing — even if not otherwise required by statewide face covering requirements; avoid touching their face; and practice good hand hygiene if they choose to spend time in the community. Clients have the same rights as others to decide how strictly they will adhere to these recommendations. Consider ways to support healthy and informed decision-making. More information on ways to stay safe while engaging in community activities can be found at CDC: How to Protect Yourselves & Others and Protect Yourself & Others: COVID-19.
Actively screen clients upon their return from community visits. Ideally, screening consists of taking the individual’s temperature and asking the following:
- Do you have Symptoms of Coronavirus, such as a fever, cough, or difficulty breathing?
- Have you come into close contact with someone who is known to have or is suspected of having COVID-19?
Templates of forms used to screen staff and monitor symptoms of clients are in the COVID-19 Toolkit: Information for Long-term Care Facilities (PDF), Appendix E and F. Adapt the templates as needed.
For clients with signs or symptoms of illness or a measured or subjective fever, it is recommended that they be isolated, per CDC Infection Control Guidance for Healthcare Professionals about Coronavirus (COVID-19), and tested for COVID-19. Measured fever means a fever objectively measured by a thermometer. Subjective fever means that the person feels warm or feverish.
For clients who have had an exposure to a person who is known to have or is suspected of having COVID-19, facilities should follow the CDC Public Health Guidance for Community-Related Exposures.
To reduce COVID-19 risk from physical interaction with the community, consider assisting with alternate methods of socialization, job searches, housing searches, shopping, and other forms of community engagement. Strategies might include use of technology to substitute for face-to-face interactions, assigning a staff person to shop on behalf of multiple clients at one time, or opening a canteen to allow on-site purchases of popular items.
For transportation guidance please see the following:
Some counties are considering the development of alternative housing options to address this type of situation. Check with your local public health department to see whether alternative housing is available, if needed. Another option is to contact other SUD providers to ask if the person could transfer to a program that has appropriate space for them during their isolation or quarantine period.
For information on how to contact your local public health department, see Find a local public health department of community board.
If a client refuses to comply with infection control recommendations:
- Try to keep those who are high risk and compliant separated from those who refuse to comply.
- Provide these clients with hand sanitizer and encourage frequent use.
- Ensure staff have all the appropriate PPE and have been trained on how to use it.
- Increase client monitoring for symptoms related to COVID-19 to at least twice a day and at re-entry into the facility.
- Consider providing an incentive or reward for clients who comply.
Admission or discharge decisions should not be based on a client’s ability or inability to comply with infection control recommendations, but rather on their overall readiness or needs to further receive inpatient treatment services. For more information on discharging individuals with potential COVID-19, see the question below, “Does COVID-19 impact discharge/aftercare planning?”
As testing resources allow, facilities may consider testing of individuals at admission. Testing should not be used to determine admission, but rather to provide more information to determine if quarantine and other infection control measures are warranted. Tests only provide a snapshot of the person’s COVID-19 status at one point in time, and it is possible that a person in the early stages of COVID-19 infection will have negative test results due to low viral loads. For this reason, MDH does not recommend that congregate care settings, including SUD facilities, rely solely on RT-PCR testing to determine how to manage admissions or re-admissions.
For more information on the use of testing strategies for individuals who may have difficulty complying with social distancing, see the CDC Morbidity and Mortality Report Screening for SARS-CoV-2 Infection Within a Psychiatric Hospital and Considerations for Limiting Transmission Within Residential Psychiatric Facilities—Wyoming, 2020.
Monitor all clients at least once a day for fever, symptoms of COVID-19, or changes in health status. Clients experiencing symptoms compatible with COVID-19 are considered to have a suspect diagnosis and should be placed on transmission-based precautions, even with no laboratory testing. Testing clients in congregate settings is a high priority and strongly encouraged due to the potential for COVID-19 to rapidly spread in these settings. A client who tests positive for COVID-19 is considered to have a confirmed diagnosis.
Staff who provide direct care to these clients should use all appropriate PPE, as resources allow.
- For prolonged close-contact encounters, staff should wear a surgical facemask or respirator and eye protection (e.g., face shield, goggles, or safety glasses with side shields). Washable homemade cloth face coverings are not considered PPE and should not be used in this situation.
- Prolonged encounters means 15 minutes or more within a 24-hour period.
- Close contact is defined as being within 6 feet of a person with confirmed COVID-19 or having unprotected direct contact with infectious secretions or excretions of the person with confirmed COVID-19.
- Use of N95 or higher-level respirators are recommended only for staff who have been medically cleared, trained, and fit tested, in the context of an employer’s respiratory protection program, as defined by the Occupational Safety and Health Administration (OSHA). Group home providers should document their good faith efforts to comply with OSHA standards for N95 use. During times of extreme supply constraints, when the availability of respirators or fit-test kits may be limited, employers may face challenges in fit testing workers. For additional guidance in these circumstances, group home providers should refer to CDC: NIOSH Science Blog: Proper N95 Respirator Use for Respiratory Protection Preparedness.
- Gowns and gloves should also be worn when contact with secretions or bodily fluids is anticipated or for any encounters that require extensive body contact (e.g., rolling, toileting).
- If performing an aerosol generating procedure, staff should wear a gown, gloves, eye protection, and respirator. See Aerosol Generating Procedures and Patients with Suspected or Confirmed COVID-19 (PDF).
The decision to discontinue these PPE precautions for clients with confirmed COVID-19 infection should be made using the CDC symptom-based strategy. The time period used depends on the client's severity of illness and if they are severely immunocompromised. See: CDC: Discontinuation of Transmission-Based Precautions and Disposition of Patients with COVID-19 in Healthcare Settings (Interim Guidance).
Clients with COVID-19 should have a single-person room with a private bathroom and a door that closes. If a private bathroom is not possible, an alternative option would be to dedicate a separate bathroom in the facility for those who have COVID-19. Staff should clean and disinfect the frequently used areas of the bathroom after each use by a person who is COVID-19 positive and clean and disinfect the entire bathroom at least twice per day, or more frequently after times of heavy use.
If possible, a plan for cohorts should be adopted to allow dedicated space, with dedicated staff, for clients who are COVID-19-positive.
Clients with confirmed or suspected COVID-19 (symptomatic or asymptomatic) should remain in their room as much as possible. If it is essential to leave their room, they should:
- Wear a surgical facemask (preferable if available) or alternative face covering, or use another barrier, such as tissues, to cover their mouth and nose.
- Perform hand hygiene immediately before or after leaving their room.
- Practice social distancing to remain at least 6 feet from others.
Clients with an exposure to a confirmed or suspected case of COVID-19 are advised to quarantine for 14 days after the last known exposure or after preventive self-isolation measures are put into place.
- A person who was identified as a positive case, has clinically recovered from COVID-19, and then identified as a contact of a new case should follow the most up-to-date CDC guidance for quarantine and testing, as these recommendations will likely differ from individuals who have not previously tested positive.
For additional information, visit the following:
Individuals who have clinically recovered from COVID-19 and then are identified as a contact of a new case within three months of symptom onset of their most recent illness do not need to be quarantined or retested for COVID-19. However, if a person is identified as a contact of a new case three 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.
In general, be mindful of the ways the COVID-19 pandemic might intensify existing or new stressors. Help clients plan and prepare for the added stressors they are likely to encounter, including access to housing, employment, health care, medications, social supports, and continued supports for recovery.
For additional information and resources visit the following:
- Disaster Mental and Behavioral Health and COVID-19
- CDC: COVID-19 Questions and Answers: For People Who Use Drugs or Have Substance Use Disorder
- CDC: Alcohol and Substance Use
Discharging clients who are COVID-19 positive
The decision to discharge a client should be made in consultation with the client, the client’s clinical care team, and local or state public health departments if the client is COVID-19 positive at the time of discharge. It should include considerations of the home’s suitability for and client’s ability to adhere to home isolation recommendations. Discharging clients into homelessness is discouraged. It is preferable to postpone discharge until a client can be transferred into an appropriate isolation setting. During isolation, ensure continuation of behavioral health support for people with substance use or mental health disorders.
For more information, see:
- CDC: Interim Guidance for Implementing Home Care of People Not Requiring Hospitalization for Coronavirus Disease 2019 (COVID-19)
- CDC: Discontinuation of Isolation for Persons with COVID-19 Not in Healthcare Settings
Discharging clients who have been exposed to COVID-19
Encourage clients who have had close contact of 6 feet or less for 15 minutes or more to quarantine. See: CDC: When to Quarantine.
These clients should stay home until 14 days after their last exposure and:
- Monitor for symptoms related to COVID-19.
- Check temperature twice a day.
- Watch for fever, cough, shortness of breath, and other symptoms of COVID-19.
- Avoid contact with people who are at higher risk for severe illness from COVID-19.
- If symptoms develop, follow CDC: What to Do If You Are Sick.
Discharging clients who have symptoms but test negative for COVID-19
Postpone discharge until 10 days after symptoms first appeared, symptoms have improved and they have been fever free for 24 hours without fever reducing medications. If the client is an adult who is able to care for themselves and maintain precautions where they will be discharged, discharge does not need to be postponed.
Discharging clients who have no symptoms and no known exposure to COVID-19
Instruct clients to monitor for symptoms for 14 days after discharge. Ask the client or receiving facility (if applicable) to inform you if the client becomes symptomatic or tests positive. This will help facilitate a timely response to identify all individuals who may have been exposed.
Reach out to local public health for assistance with essential needs, as they may have networks with community organizations that can assist. Visit Minnesota COVID-19 Response: Get Help for additional resources for food, housing, mental health, and more. In general, be mindful of the ways the COVID-19 pandemic may intensify existing or new stressors. Help clients plan and prepare for the added stressors they are likely to encounter, including access to housing, employment, health care, medications, social supports, and continued supports for recovery.
Providers should reference the “Cardiopulmonary Resuscitation (CPR) in Patients with Known or Suspected COVID-19” section in Aerosol –Generating Procedures and Patients with Suspected or Confirmed COVID-19 (PDF).
Limit visitation to those who are considered essential in the client’s life and encourage a minimal number of visitors present at one time during a visit in order to practice social distancing as much as possible within the meeting space. Screen visitors prior to entrance for symptoms of illness or a measured or subjective fever and designate a location for visits that is close to the facility entrance that can be easily cleaned and disinfected afterwards. These locations should have access to hand hygiene stations before and after visits.
Clients and visitors should practice social distancing and must wear a cloth face covering for source control, as required by executive order and facility policy. Have face coverings available for visitors if they do not bring their own. Encourage clients and visitors to avoid touching their eyes, nose, and mouth; and to cover their cough. Consider posting signage to remind and reinforce these practices.
Outdoor visitation is recommended as much as possible, weather permitting, to further reduce the risk of disease transmission during the visit. For additional guidance, see Outdoor Visitation Guidance for Long-term Care Facilities (PDF).
Clients who are symptomatic or under isolation or quarantine should attend groups virtually from their room or a private area with headphones. If the headphones are going to be used by multiple users, they should have a cleanable surface or disposable cover and should be properly disinfected with an EPA-registered product after each use. A list of disinfectants effective against COVID-19 is available at EPA: List N: Disinfectants for Use Against SARS-CoV-2 (COVID-19).
For all other clients, virtual group attendance is encouraged in a private, soundproof room that can be easily cleaned and disinfected after each use. If no room is available or a client wants to attend from their room, headphones that are not used for symptomatic individuals is encouraged. Disinfect headphones appropriately after each use.
The guidance for facilities that serve adults and adolescents are similar. Social distancing, appropriate personal protective equipment (PPE), good hand hygiene, symptom screening, and other general infection control recommendations are encouraged.
For specific guidance for adolescents, see Questions and Answers for Staff, Families, and Clients of Children's Residential Facilities: COVID-19.
Facilities that house clients’ children on-site should consider implementing strong infection control practices to help prevent the spread of COVID-19. Strong education about COVID-19 and discussion groups may help children understand the illness, correct misinformation, and cope with the virus and its impacts. It is important to keep education simple and to have the children actively engaged.
You can find information specifically related to children and congregate housing in the following resources:
At this time, it is unknown how long regulatory modifications will need to remain in effect. Monitor Minnesota Department of Human Services (DHS) websites for current information:
All facilities are encouraged to assume that anyone could have COVID-19 due to the prevalence of the disease in Minnesota. For information on facilities that have reported 10 or more cases, visit Situation Update for COVID-19.