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DOH and CDC Issue Return to Work Guidance

The Centers for Disease Control and Prevention (CDC) and the Department of Health (DOH) updated and issued guidance on Dec. 23rd and 24th, respectively, reducing the time that personnel must be excluded from work as a result of a COVID-19 infection or exposure. The state and federal guidance differ in scope and approach:

LeadingAge NY has asked DOH whether it is also accepting the updated CDC guidance on Managing Healthcare Personnel and Strategies to Mitigate Staffing Shortages, but has not received a response. However, the most recent DOH nursing home testing guidance links to the CDC guidance on Managing Healthcare Personnel, indicating DOH's endorsement of the version in effect at the time of publication and suggesting that DOH may continue to follow the CDC's guidance. In the absence of any clarification or contrary guidance, providers should consider the following:

  • Adhering to the DOH return to work guidance with respect to fully vaccinated personnel who are infected with COVID-19, if the provider is experiencing a critical staffing shortage;
  • Adhering to the CDC guidance on Managing Healthcare Personnel with respect to HCP who are infected with COVID-19, if the health care provider is not experiencing a critical staffing shortage;
  • Adhering to the CDC guidance on Managing Healthcare Personnel and Strategies to Mitigate Healthcare Workforce Shortages with respect to HCP who are exposed to COVID-19 but not infected.

Providers are encouraged to consult with their infection prevention professionals, human resources, DOH regional offices, and local health departments as appropriate.

On Dec. 26th, the CDC also updated guidance governing the duration of isolation and quarantine. The isolation and quarantine guidance is intended to apply to the general public, rather than HCP specifically.

The following are brief summaries of the HCP guidance documents. Members are encouraged to read the documents in their entirety.

DOH Guidance for HCP and Critical Workforce with COVID-19 Infections

Health care providers and employers of critical workforce should follow the DOH guidance when staff are infected with COVID-19 and the organization is experiencing a critical staffing shortage.

a) Who is eligible for a reduced period of work exclusion?

HCP and critical workforce members are eligible for a reduced period of work exclusion if they meet all of the following criteria:

  • Fully vaccinated (e.g., completed one dose of Janssen or two doses of an mRNA vaccine at least two weeks before the day they become symptomatic or, if asymptomatic, the day of collection of the first positive specimen).
  • Asymptomatic, or, if they had mild symptoms, when they return to work, they must:
    • Not have a fever for at least 72 hours without fever-reducing medication
    • Have resolution of symptoms, or, if still with residual symptoms, then all are improving
    • Not have rhinorrhea (runny nose)
    • Have no more than minimal, non-productive cough (i.e., not disruptive to work and does not stop the person from wearing their mask continuously, not coughing up phlegm)
  • Able to consistently and correctly wear a well-fitting face mask, a higher-level mask such as a KN95, or a fit-tested N95 respirator while at work. The mask should fit with no air gaps around the edges.

The guidance includes an appendix listing the various types of employment and organizations covered, which include residential health care facilities, home care, senior/elder care, congregate care facilities, and human services providers. It appears that staff working in senior housing/independent living are also covered by this guidance, as they would fall under the categories of workers essential to maintain operations of residences, human services providers, and/or senior/elder care.

b) How long is the work exclusion period for infected individuals under this policy?

Where there is a critical staffing shortage, employers may allow a person to return to work after day five of their isolation period (where day zero is defined as either date of symptom onset if symptomatic or date of collection of first positive test if asymptomatic). Testing is not required as a prerequisite for returning to work.

c) What should employers and personnel do when they return to work after a reduced period of exclusion under this policy?

Individuals who work in health care settings should:

  • Be restricted from contact with severely immunocompromised patients (e.g., transplant, hematology-oncology, neonatal ICU).
  • Wear a respirator or well-fitting surgical face mask even when the individual is in non-patient care areas such as breakrooms or offices.

All workers participating in this program should be instructed that:

  • They should practice social distancing from coworkers at all times except when job duties do not permit such distancing. If they must remove their respirator or well-fitting face mask, for example, in order to eat or drink, they should separate themselves from others.
  • They should self-monitor for symptoms and seek re-evaluation from occupational health or their personal health care provider if symptoms recur or worsen.
  • They must continue to stay at home, take precautions to avoid household transmission, and observe other required elements of isolation while not at work until the end of the 10-day period.

d) What is a critical staffing shortage?

The guidance does not define critical staffing shortage, nor does it indicate the entity responsible for determining whether a critical staffing shortage exists. LeadingAge NY has asked DOH these questions, but has not received a response. While we are waiting for a reply, we recommend the following:

  • Determine whether your organization is experiencing a "critical staffing shortage." One source for evaluating your staffing situation and addressing it is the CDC guidance on Strategies to Mitigate Healthcare Personnel Staffing Shortages (discussed further below). That guidance defines the trigger for implementing "contingency capacity strategies" as "[w]hen staffing shortages are anticipated" and the trigger for "crisis capacity strategies" as "[w]hen there are no longer enough staff to provide safe patient care . . ." (Notably, the five-day work exclusion period for individuals infected with COVID-19 is listed as a "contingency capacity" strategy in the CDC guidance.) The DOH guidance applies "where there is a critical staffing shortage" – not where one is merely anticipated. Arguably, since providers must have the discretion to take steps to avoid a crisis situation, a critical staffing shortage under the DOH guidance may lie somewhere between the anticipation of a shortage and a crisis, when measures must be implemented to ensure continuation of safe patient care.
  • If your organization believes that it is experiencing a critical staffing shortage, it should document the extent of the shortage, the options and strategies it has pursued to staff appropriately and mitigate the shortage, and its determination that the organization is experiencing a critical situation.
  • Contact the DOH Surge and Flex Operations Center at 917-909-2676 and notify them of your staffing situation.
  • Contact your regional office and notify them that you are activating your policy under the DOH guidance.

CDC Guidance on Managing HCP with COVID-19 Infection or Exposure

The CDC guidance applies to certain situations in which the DOH guidance is inapplicable – i.e., exposures of HCP and in the absence of a critical staffing shortage. Although DOH has not indicated its position on the CDC guidance, in the absence of any clarifications, health care providers might consider implementing the CDC guidance if they are experiencing conventional staffing capacity or if they have staff who have been exposed to the virus but are not infected.

a) What is the CDC guidance on return to work after a COVID-19 infection under conventional staffing capacity?

The CDC guidance for conventional staffing situations reduces the duration of work exclusion for HCP with a COVID-19 infection to at least seven days under the following circumstances:

  • HCP has mild to moderate illness and is not immunocompromised; and
    • A negative test result is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive result is received at day five to seven); and
    • At least 24 hours have passed since last fever without use of medication, and symptoms have improved.
  • HCP was asymptomatic throughout their infection and is not immunocompromised.
    • A negative test result is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or a positive result is obtained at day five to seven).

HCP with severe to critical illness who are not immunocompromised must be excluded until 20 days after the appearance of symptoms and at least 24 hours have passed since last fever without medication, and symptoms are improving. A test-based strategy may also be used to inform the duration of their work exclusion. For HCP who are moderately to severely immunocompromised, a test-based strategy should be used in consultation with an infectious disease specialist or other specialist to determine when they may return to work.

b) What is the CDC guidance for HCP after an exposure under conventional staffing capacity?

The CDC guidance for HCP with high-risk exposures reduces the work exclusion from 14 days to seven or 10 days for certain HCP, but now requires work exclusion for certain vaccinated and un-boosted HCP. The guidance provides for different periods of exclusion from work depending on the vaccination status of the HCP, the personal protective equipment (PPE) worn by the HCP and the person infected with COVID-19, and the existence and extent of staffing shortages in the organization.

Notably, if the HCP with a higher-risk exposure was wearing recommended PPE and is asymptomatic, there is no need to exclude the HCP from work, regardless of their vaccination status. If the HCP with a higher-risk exposure was not wearing all recommended PPE, but is vaccinated and boosted, they do not have to be excluded from work if asymptomatic, but must be tested after 24 hours and at day five to seven. 

For HCP with a higher-risk exposure who were not wearing the recommended PPE and were either unvaccinated or not boosted, the CDC guidance reduces the period of work exclusion after high-risk exposures as follows:

  • Exclude from work for seven days with a negative test within 48 hours prior to return, if asymptomatic; or
  • Exclude from work for 10 days if not tested, if asymptomatic.

The new CDC guidance also modifies the risk assessment for exposures to include distances of more than six feet when exposures occur over long periods of time in indoor areas with poor ventilation.

The CDC guidance includes two helpful charts:

  • A summary of the exposure risk assessment and responses here;
  • A summary of the work exclusion guidance under various scenarios here.

c) Does the CDC guidance permit even shorter work exclusion periods in the context of workforce shortages?

The CDC updated separate guidance on Strategies to Mitigate Healthcare Personnel Staffing Shortages at the same time as the update on Managing Healthcare Personnel. This guidance provides a continuum of mitigation strategies to address staffing shortages. The options begin with contingency strategies to be considered when health care providers are anticipating staffing shortages in order to prepare for and mitigate those shortages. Once contingency strategies have been implemented, if staffing shortages still materialize and there are no longer enough staff to provide safe patient care, health care providers may consider and implement crisis capacity strategies. These strategies are delineated in the guidance.

d) What tests should organizations use to determine whether individuals must be excluded from work or may return to work?

The CDC Managing Healthcare Personnel guidance notes that health care providers should ensure that the COVID-19 tests they are using are capable of detecting the variants that are currently circulating. The Food and Drug Administration (FDA) recently released a memorandum identifying certain tests that are not able to detect the Omicron variant. The memorandum is available here.

LeadingAge NY will continue to seek further clarity from DOH on their intentions and to advocate for additional resources for long term care providers. We will keep members apprised of any updates.

Contact: Karen Lipson, klipson@leadingageny.org, 518-867-8838