City and County of San Francisco Department of Public Health Order of the Health Officer ORDER OF THE HEALTH OFFICER No. C19-03b ORDER OF THE HEALTH OFFICER OF THE CITY AND COUNTY OF SAN FRANCISCO DIRECTING RESIDENTIAL FACILITIES TO LIMIT VISITORS AND OTHER NONESSENTIAL PERSONS AND TO PREPARE WRITTEN PROTOCOLS REGARDING COVID-19, INCLUDING RESTRICTIONS ON AND SCREENING OF VISITORS AND OTHER PROTECTIONS FOR RESIDENTS, VISITORS, AND PERSONNEL (PUBLIC HEALTH EMERGENCY ORDER) DATE OF ORDER: September 4, 2020 Please read this Order carefully. Violation of or failure to comply with this Order is a misdemeanor punishable by fine, imprisonment, or both. (California Health and Safety Code § 120275, 120295, et seq.; Cal. Penal Code §§ 69, 148(a)(1); San Francisco Administrative Code §7.17(b)) Summary: On February 25, 2020, the Mayor of the City and County of San Francisco (the “City”) declared a state of emergency to prepare for coronavirus disease 2019 (“COVID-19”). On March 5, 2020 there was the first reported case of COVID-19 in the City. On March 16, 2020, the City and five other Bay Area counties and the City of Berkeley, working together, were the first in the State to implement shelter-in-place orders in a collective effort to reduce the impact of SARS-CoV-2, the virus that causes COVID-19. That virus is easily transmitted, especially indoors or in group settings, and the disease can be extremely serious. It can require long hospital stays, and in some instances cause long-term health consequences or death. It can impact not only those who are older or have underlying health conditions and known to be at high risk, but also other people, regardless of age. And a major risk remains the spread of the virus that causes COVID-19 through asymptomatic and pre-symptomatic carriers, people who can spread the disease but do not even know they are infected and contagious. The spread of disease is a global pandemic causing untold societal, social, and economic harm. On March 7, 2020, the City’s Health Officer issued Order No. C19-01, limiting visitors and non-essential personnel from Laguna Honda Hospital, one of the largest skilled nursing facilities in the country. On March 10, 2020, the first version of this Order, C19-03, was issued to extend similar restrictions and other safety measures to other skilled nursing and residential facilities in the City. Order No. C19-01 was expanded on March 11, 2020, to include the skilled nursing unit at Zuckerberg San Francisco General Hospital and add the additional safety requirements. On March 18, 2020, the Health Officer issued Order No. C19-09, extending similar restrictions and protections to other residential living facilities in the City. Collectively, these orders served to protect residents and staff at residential living facilities in the City. 1 City and County of San Francisco Department of Public Health Order of the Health Officer ORDER OF THE HEALTH OFFICER No. C19-03b Some residents of community living facilities are being treated for health conditions that make them particularly vulnerable to suffering the most serious complications of COVID-19, including death. Community living settings also make it easier for the virus to spread. And medical personnel and other essential staff of hospitals and residential facilities are experiencing increased stress associated with providing excellent support during this public health emergency. It is critical to protect all these populations from avoidable exposure to the disease and other pathogens. At the same time, allowing visitation in such settings is also important to the health and well-being of residents, many of whom have gone without in-person visits for almost six months. The Health Officer and the Department of Public Health (“DPH”) have been reviewing the literature and data to help craft rules that will expand visitation in safer ways while also continuing to protect these populations. Although our collective effort has had a positive impact on limiting the spread of the virus, key concerns remain. The number of infections and infection rate in the City remain high, and it is anticipated that infection rates will continue to increase as we enter the Fall (when the flu and colds could negatively impact health in these facilities) and other activities are further allowed under state and local orders. We are going to have to live with the threat of the virus for many months to come. This Order expands visitation at Residential Facilities, accomplishing the purpose of strengthening our community social distancing response, protecting medical resources and healthcare providers, and supporting the well-being of residents by allowing for inperson visits when they can be done safely. The Order gives such facilities flexibility to allow three new kinds of visitation: outdoor visits (where resident and visitor are outside), vehicle-based visits (where the visitors remain in a vehicle), and facility window visits (where the resident remains in the building behind a window or door with a window). This Order lists many requirements for allowing such visits, including mandatory screening of visitors on the day of the visit, mandatory physical distancing, wearing a face covering as required by Health Officer Order No. C19-12c, a prohibition on direct exchange of gifts or other items between the resident and visitors, a requirement that visits be scheduled in advance, restrictions on the length of visits and how many visitors are allowed, and other protections. Residential Facilities are given leeway to determine how to safely offer such visits and what kinds of visits they wish to offer, although they must contact the California Department of Public Health (“CDPH”) if they are unable to allow for some version of this expanded visitation. This Order also makes other changes, cleaning up the prior requirements, adding a checklist of key visitation requirements, and requiring Residential Facilities to notify residents and authorized decision makers of these changes. This Order goes into effect at 9 a.m. on Saturday, September 5, 2020, revises and replaces the prior version (Order No. C19-03) as of that time and date, and will remain in effect until extended, rescinded, superseded, or amended in writing by the Health Officer. 2 City and County of San Francisco Department of Public Health Order of the Health Officer ORDER OF THE HEALTH OFFICER No. C19-03b Table of Contents: 1. Intent ........................................................................................................................................ 4 2. General Requirements ............................................................................................................. 4 3. Visitation Restrictions and Requirements ............................................................................... 4 4. Types of Visitation .................................................................................................................. 4 5. Allowed Visitation................................................................................................................... 5 a. General Visitation Requirements ......................................................................................... 5 b. Facility Window Visit Requirements .................................................................................. 8 c. Vehicle Visit Requirements ................................................................................................. 9 d. Outdoor Visit Requirements .............................................................................................. 10 6. COVID-19 Prerequisites and Outbreak Restrictions ............................................................. 11 a. Prerequisites ....................................................................................................................... 11 b. Visit-Related Outbreak Restrictions .................................................................................. 12 7. Necessary Visitation .............................................................................................................. 12 8. Visitor Screening Procedures ................................................................................................ 13 9. Other COVID-19 Related Protocols ...................................................................................... 13 10. Non-Essential Resident Movement is Discouraged........................................................... 13 11. Face Coverings .................................................................................................................. 14 12. Written COVID-19 Plan Requirement............................................................................... 14 13. Staff Screening ................................................................................................................... 15 14. Staff and Resident Testing ................................................................................................. 15 15. COVID-19 Guidance ......................................................................................................... 15 16. Non-Compliance ................................................................................................................ 15 17. No Restriction on First Responders, Others ...................................................................... 15 18. Definitions ......................................................................................................................... 15 19. Licensing Entity Notification............................................................................................. 16 20. List of Residential Facilities .............................................................................................. 17 21. Complaints ......................................................................................................................... 17 22. Continuing Severe Health and Safety Risk Posed by COVID-19 ..................................... 17 23. Cases, Hospitalizations, and Deaths .................................................................................. 18 24. Incorporation of State and Local Emergency Proclamations and State Health Orders ..... 18 a. State and Local Emergency Proclamations ....................................................................... 18 3 City and County of San Francisco Department of Public Health Order of the Health Officer ORDER OF THE HEALTH OFFICER No. C19-03b b. 25. State Health Orders ............................................................................................................ 18 Effective Date .................................................................................................................... 19 26. Reporting Violations. ......................................................................................................... 19 27. Copies and Notice .............................................................................................................. 19 28. Severability ........................................................................................................................ 19 29. Interpretation ...................................................................................................................... 19 UNDER THE AUTHORITY OF CALIFORNIA HEALTH AND SAFETY CODE SECTIONS 101040, 101085, AND 120175, THE HEALTH OFFICER OF THE CITY AND COUNTY OF SAN FRANCISCO (THE “HEALTH OFFICER”) ORDERS: 1. Intent. The intent of this Order is to ensure that residents, staff, and Visitors at each long-term care residential facility listed in Section 20 below (each a “Residential Facility”) are protected from the spread of COVID-19 to the greatest extent possible given how vulnerable most residents at Residential Facilities in the City are to the disease and how easy it is to transmit the SARS-CoV-2, the virus that causes COVID-19, especially from asymptomatic and pre-symptomatic people. Other capitalized terms in this Order are defined throughout this Order. 2. General Requirements. While this Order is in effect, each Residential Facility and the staff of each such Residential Facility must comply with the visitation and COVID-19 related protocols listed by this Order as well as all other requirements of this Order. Visitors allowed under this Order must comply with all conditions of visitation imposed by this Order and by the Residential Facility at the time of entry or access to the Premises. 3. Visitation Restrictions and Requirements. Each Residential Facility and its staff must exclude from entry or access to its Premises any Visitors and Non-Essential Personnel including, but not limited to, visitors of residents at the Residential Facility except as allowed by this Order. Such Visitors and Non-Essential Personnel, including but not limited to authorized decision-makers and family members of residents, are ordered not to visit any Residential Facility except as allowed by this Order. 4. Types of Visitation. This Order restricts onsite visits between Residential Facility residents and Visitors. When Visitors seek to visit or contact a resident, the Residential Facility may allow visitation or contact only in the following ways. First, each Residential Facility must make reasonable efforts to facilitate such contact by remote means such as telephone or videoconference that do not expose the resident to in-person contact. Second, each Residential Facility may authorize Allowed Visitation or Necessary Visitation on a case-by-case basis using the 4 City and County of San Francisco Department of Public Health Order of the Health Officer ORDER OF THE HEALTH OFFICER No. C19-03b following protocols and other protocols regarding visitation it puts in place. Based on the context, a Residential Facility may refuse Allowed Visitation or Necessary Visitation when visits cannot occur in a manner that protects the health and welfare of the resident, the Visitor, and Residential Facility personnel. Each Residential Facility must monitor and ensure compliance with the requirements of this Order. 5. Allowed Visitation. The term “Allowed Visitation” means an in-person visit or contact that occurs between a resident and a Visitor under this Section 5. Allowed Visitation includes Facility Window Visits, Vehicle Visits, and Outdoor Visits, each as defined in this Section. Allowed Visitation, regardless of type, may only occur when the Residential Facility complies with all General Visitation Requirements listed below and also each requirement that applies to the specific type of visit. The checklist attached as Appendix A to this Order outlines most requirements for Allowed Visitation, but all requirements listed in the body of this Order must be met. Each Residential Facility should offer at least one type of Allowed Visitation except when that cannot be done safely and is encouraged to offer multiple types when staffing, resources, and the context permit doing so safely. If a facility is unable to offer any form of Allowed Visitation (other than temporarily based on short-term staffing or other conditions), it must notify CDPH with an explanation of why it is unable to offer such visitation. Safety considerations for visits include not only COVID-19-related issues but more typical resident safety issues to ensure that risks to resident safety and well-being are minimized whenever possible. In relation to implementation of Allowed Visitation, a Residential Facility may utilize trained volunteers to help meet the requirements of this Order so long as such volunteers, if onsite, are screened and meet other applicable requirements for staff. Examples of each type of Allowed Visitation are included below, and these are for illustration purposes and are not intended to show the only way that visitation may occur. This Order gives discretion to each Residential Facility to implement visitation in the ways that make the most sense and that protect resident, staff, and Visitor safety in the facility’s unique setting. a. General Visitation Requirements. Each visit that occurs as an Allowed Visitation must comply with all of the following requirements (the “General Visitation Requirements”): i. All visits are subject to the COVID-19 Prerequisites and Outbreak Restrictions listed in Section 6 below. ii. The visit must be supervised by Residential Facility staff or trained, screened volunteers for the duration of the visit. iii. The visit must be planned in advance with the Residential Facility, and the Residential Facility may determine the visitation hours for each type of Allowed Visitation. 5 City and County of San Francisco Department of Public Health Order of the Health Officer ORDER OF THE HEALTH OFFICER No. C19-03b iv. The Residential Facility must designate an appropriate area for the type of Allowed Visitation. If the Residential Facility does not have an area that meets all requirements a specific type of Allowed Visitation, then the Residential Facility must not allow that type of Allowed Visitation to occur. v. When a resident moves to or is transported to any area designated for Allowed Visitation, the resident must wear a Face Covering (as tolerated) for that journey. Except as listed below, a resident must wear a Face Covering (as tolerated) for the duration of the visit. Except as listed below, each Visitor must wear a Face Covering at all times. The rules regarding Face Coverings are listed below in Section 11. vi. The Residential Facility must provide a telephone on request to any resident who remains inside the building during a visit so that Visitors can safely communicate with the resident, such as from afar or through closed windows. vii. Sharing items between Visitors and residents, including gifts, flowers, reading materials, games, food, drinks, or utensils, during any visit is not allowed. A Residential Facility may adopt a protocol for allowing Visitors or others to send or deliver items or gifts to residents through Residential Facility staff so long as the protocol addresses how to ensure resident safety and minimize the risk of disease transmission through surface contact. Such a protocol may not allow Visitors to hand such items directly to a resident during a visit. viii. Except as listed below, each Visitor and Visitor group must maintain at least six feet or more of physical distancing from all other groups and from all residents, including the resident they are visiting. No physical touching is allowed between a Visitor and any resident (meaning no hugging, hand-shaking, kissing, etc.). The Residential Facility must post signs outlining these rules, clearly mark spaces to prevent Visitor groups from being too close to each other or to residents, limit crowding, and increase the distance between groups as needed to ensure that people can hear each other without having to shout to be heard. Sample signs will be available online soon at https://www.sfcdcp.org/infectious-diseases-a-to-z/coronavirus-2019novel-coronavirus/coronavirus-2019-information-for-healthcareproviders/ under the “Long Term Care and Senior Care” list. ix. No more than four Visitors from the same household are allowed. If visitors are from different households, the group of Visitors must be limited to two people total (one per different household). Visitation 6 City and County of San Francisco Department of Public Health Order of the Health Officer ORDER OF THE HEALTH OFFICER No. C19-03b group size can be limited by the Resident Facility based on facility space or other safety considerations to allow for proper distancing. x. The Residential Facility must screen visitors for COVID-19 Symptoms (as defined in Section 18.e below) prior to the start of the visit as outlined in Section 7 below. For Outdoor Visits, temperature screening of each Visitor is also required. xi. No visitor who answers a screening question indicating they have any of the COVID-19 Symptoms or who otherwise answers questions indicating that they have recent exposure to SARS-CoV-2 is allowed to visit. xii. Except for Vehicle Visits with Closed Facility Windows, the Residential Facility must require Visitors to perform hand hygiene in accordance with guidelines from the United States Centers for Disease Control and Prevention and provide supplies for hand hygiene such as hand sanitizer or a sink with soap, clean water, and towels as appropriate. More information on hand hygiene is available at https://www.cdc.gov/handwashing/when-how-handwashing.html and https://www.cdc.gov/handwashing/hand-sanitizer-use.html. xiii. The Residential Facility must routinely clean and disinfect all frequently touched surfaces under the control of the Residential Facility in any area used for visits. xiv. Each visit is limited to one hour, and a Residential Facility may impose shorter time limits if needed to accommodate residents while ensuring compliance with the requirements of this Order. A Residential Facility may also limit the number of visits per resident each week, month, or otherwise in order to ensure that all residents are able to have visitors in a fair and equitable manner and take into account the context of a given resident. xv. A visit may be cancelled by the Residential Facility due to relevant considerations that impact Visitor, staff, or resident safety. xvi. Whenever possible, visitation should take place without visitors walking through the interior of a Residential Facility. If visitors must travel through the interior of a Residential Facility, the facility should have them take the shortest route possible. By way of example, it is acceptable for Visitors to walk through a facility’s lobby to get to an outdoor garden or courtyard where Outdoor Visitation occurs (so long as travel through the building is not restricted at the time under Section 6 below). 7 City and County of San Francisco Department of Public Health Order of the Health Officer ORDER OF THE HEALTH OFFICER No. C19-03b xvii. Shouting, singing, or playing instruments that use the human breath (such as woodwind or brass instruments) is prohibited except when everyone is behind closed windows. xviii. Except for Vehicle Visitation, visitation by children is left to the discretion of the Residential Facility. If children are allowed to visit, all Visitors who are two years old and older must wear a face covering, and children must be under supervision at all times. Also, screening for any COVID-19 Symptoms must take into account the different list of symptoms for youths under 18 years old (see Section 18.e below). b. Facility Window Visit Requirements. The term “Facility Window Visit” refers a visit where the Visitor(s) are separated by a building window (or door with a window) from the resident. There are two types of Facility Window Visits: a Facility Window Visit with an Open Window, which is when the window separating the Visitor(s) and resident is open and the Visitor(s) are outdoors; and a Facility Window Visit with a Closed Window, which is when the window separating the Visitor(s) and the resident is closed so no airflow occurs between the two sides of the window. The following are examples of a Facility Window Visit with an Open Window: a resident in their room on the first floor with window open to a garden or walkway where the Visitors are located; a resident in part of a common area that has privacy and a window that opens out on a parking lot where the Visitors are located; and a resident in a recreation room that has a sliding glass door open to a patio that is accessible to the Visitors. The following are examples of a Facility Window Visit with a Closed Window: a resident in their room on the first floor behind a closed window talking by phone with Visitors who are outside on a walkway or in a garden; a resident in a part of the facility lobby that has large windows that do not open talking by phone with Visitors who are on the other side of the window and distant from other people entering the building; or a resident who is seated behind a door with a large window that is closed talking by phone with Visitors who are standing in a parking lot on the other side of the door. Facility Window Visits may only occur when all listed requirements for that type of visit are met. Those requirements are: i. For Facility Window Visits with an Open Window: 1. The Visitor(s) must be separated by a building window (or door with a window) from the resident. 2. The window separating the Visitor(s) and the resident may be open and the Visitor(s) are outdoors. 8 City and County of San Francisco Department of Public Health Order of the Health Officer ORDER OF THE HEALTH OFFICER No. C19-03b 3. The resident must stay at least 3 feet back from the window. 4. Each Visitor must stay at least 3 feet back from the window. ii. For Facility Window Visit with a Closed Window: 1. The Visitor(s) must be separated by a building window (or door with a window) from the resident. 2. All windows and doors separating the Visitor(s) and the resident are closed so that no airflow occurs between the two sides of the window. 3. Each Visitor is not required to maintain at least six feet or more of physical distancing the resident they are visiting because the windows and doors are closed. 4. Each Visitor is prohibited from walking through any building of the Residential Facility. c. Vehicle Visit Requirements. The term “Vehicle Visit” refers a visit where the Visitor(s) remain in a vehicle and the resident is at least six feet away from the vehicle. There are two types of Vehicle Visits: a Vehicle Visit with Open Windows, which is when any windows separating the Visitor(s) and resident are open; and a Vehicle Visit with Closed Facility Windows, which is when the resident is behind a closed window in the Residential Facility so no airflow occurs between the two sides of the window. The following are examples of a Vehicle Visit with Open Windows: a resident in a wheelchair is positioned on a walkway near a parked car talking through open car windows with Visitors who are seated in the car; and a resident sitting outside on the patio of their room talking with Visitors through open car windows of a car parked nearby. The following are examples of a Vehicle Visit with Closed Facility Windows: a resident standing at a window that does not open in the building lobby talking by phone with Visitors parked just outside in the parking lot; and a resident sitting at a closed window in their room talking by phone with Visitors parked on the street outside the window. Vehicle Visits may only occur when all listed requirements for that type of visit are met. Those requirements are: i. For Vehicle Visits with Open Windows: 1. The Visitor(s) must remain in a vehicle and the resident must be at least six feet away from any open window in the vehicle. 9 City and County of San Francisco Department of Public Health Order of the Health Officer ORDER OF THE HEALTH OFFICER No. C19-03b The resident may be outdoors or indoors at the Residential Facility. 2. The window separating the Visitor(s) and the resident may be open and the vehicle remains outdoors. 3. If there is a pull-in area for vehicle visits, the visits must be scheduled to prevent crowding and keep at least six feet between residents and at least six feet between vehicles. 4. To reduce air flow to the resident from the vehicle, the vehicle window that is closest to the resident should remain closed, if possible. ii. For Vehicle Visits with Closed Facility Windows (which is similar to a Facility Window Visit with a Closed Window): 1. The Visitor(s) must remain in a vehicle and the resident must be indoors at the Residential Facility and at least six feet away from the vehicle. 2. The Residential Facility windows separating the Visitor(s) and the resident must be closed so that no airflow occurs between the two sides of the window. The vehicle windows may be open or closed. 3. If the vehicle is parked or stopped in an area were other people will be passing, each Visitor in the vehicle must wear a Face Covering. If the vehicle windows remain closed at all times, a Face Covering is not required for Visitors in the vehicle. 4. Each Visitor is prohibited from walking through any building of the Residential Facility. d. Outdoor Visit Requirements. The term “Outdoor Visit” refers a visit where the Visitor(s) and the resident are all in an outdoor setting. The following are examples of an Outdoor Visit: a resident who is brought to a garden in front of the facility where lines are marked to help keep them at least six feet away from Visitors who are outside in the same garden; a resident who is sitting in their wheelchair on a sidewalk where the resident is ten feet away from Visitors who are also on the sidewalk and behind an optional Plexiglas barrier that the facility has put up to help protect the resident; a resident who is seated in an interior courtyard that is open to the air where the Visitor is brought through the building lobby and then directed to remain at least six feet away during the outdoor visit; and a resident who is in the 10 City and County of San Francisco Department of Public Health Order of the Health Officer ORDER OF THE HEALTH OFFICER No. C19-03b parking lot under a canopy tent that only has one wall for protection from the sun or other weather where the Visitor is also under the canopy at least six feet distant. Outdoor Visits may only occur when all listed requirements are met. Those requirements are: i. The visit must occur outdoors. If the weather does not permit the Outdoor Visit to occur, the Residential Facility may postpone or cancel the visit or provide one of the other forms of visitation allowed by this Order in line with all listed requirements. ii. In addition to symptom screening and asking other screening questions of all Visitors participating in an Outdoor Visit as required in Section 7 below, a Residential Facility must conduct temperature screening of all Visitors participating in an Outdoor Visit. iii. If a Residential Facility uses a tent or other temporary structure in relation to an Outdoor Visit, the Residential Facility must follow the requirements of Health Officer Order No. C19-07h, including as that order is revised in the future. That order currently notes that operations under a tent, canopy, or other sun or weather shelter may occur only as long as no more than one side is of the structure is closed, allowing sufficient outdoor air movement. 6. COVID-19 Prerequisites and Outbreak Restrictions. For Allowed Visitation, there are certain prerequisites that apply to different kinds of visits, and if there is a COVID-19 outbreak at the Residential Facility, there are certain visitation restrictions that apply until the outbreak is resolved. Note that any Residential Facility that has multiple units or floors may contact the Department of Public Health Outbreak Management Group (“OMG”) for permission to treat each unit or floor as a separate Residential Facility for purposes of this Section 6. OMG may be reached by phone by calling 415-554-2830, selecting Option 1, and then following the prompts for Senior Care Facilities. a. Prerequisites. For Facility Window Visits with an Open Window, Vehicle Visits with Open Windows, and Outdoor Visits: i. No visit is allowed for any resident who has any of the COVID-19 Symptoms, is in isolation or quarantine related to COVID-19, or has a COVID-19 diagnosis; and ii. There must be an absence of new COVID-19 cases or SARS-CoV-2 infections in the Residential Facility for the preceding 14 days (including residents and staff) and the Residential Facility must not be 11 City and County of San Francisco Department of Public Health Order of the Health Officer ORDER OF THE HEALTH OFFICER No. C19-03b in the surveillance period for an active outbreak. If these prerequisites are not met, then the types of visits listed in this subsection a. may not occur until the prerequisites are met. As noted above, any Residential Facility that has multiple units or floors may contact OMG for permission to treat each unit or floor as a separate Residential Facility for purposes of this Section 6. b. Visit-Related Outbreak Restrictions. If there is reason to believe that the Residential Facility has had a new COVID-19 case or SARS-CoV-2 infection, the following restrictions apply: i. For Facility Window Visits with an Open Window, Vehicle Visits with Open Windows, and Outdoor Visits, Allowed Visitation must be postponed until the requirements of Section 6.a above are met. Residential Facilities with multiple units or floors may contact OMG to determine if the Residential Facility can safely cohort to allow visitation for residents in non-outbreak units. ii. For Facility Window Visits with a Closed Window and Vehicle Visits with Closed Facility Windows, visitation may continue but each Visitor is prohibited from walking through any building of the Residential Facility. Any Residential Facility that has questions about what constitutes an outbreak or other questions about this section may contact OMG. 7. Necessary Visitation. The term “Necessary Visitation” means a visit or contact that is based on urgent health, legal, or other issues that cannot wait and that needs to occur in addition to Allowed Visitation. If the needs and context of a particular request for Necessary Visitation justifies visitation in a manner other than Allowed Visitation, then the Residential Facility Administrator may arrange for Necessary Visitation of a resident. For purposes of this Order, the Residential Facility Administrator may act through a designee. The decision about whether the needs and context justify Necessary Visitation is left to the determination of the Residential Facility Administrator, who must make the decision based on this Order and the COVID-19 Guidance. Also, any Necessary Visitation allowed under this Section must be done subject to requirements of the COVID-19 Guidance and as otherwise deemed appropriate by the Residential Facility. All Visitors allowed under this Section 6 must comply with subsections v, vii, x, xii, xiii, and xvii of the General Visitation Requirements above. 12 City and County of San Francisco Department of Public Health Order of the Health Officer ORDER OF THE HEALTH OFFICER No. C19-03b 8. Visitor Screening Procedures. Each Residential Facility must use the following screening procedures for all Visitors. The Residential Facility must screen each Visitor on the day of the visit before the visit in a manner consistent with current DPH guidance (which takes into account guidance from CDPH and the United States Centers for Disease Control and Prevention (“CDC”)) regarding screening. At a minimum, the screening must address current or recent: actual or suspected COVID-19 diagnosis; actual or suspected SARS-CoV-2 infection; actual or suspected close contact with someone with the virus; and COVID-19 Symptoms (listed below in Section 18.e) consistent with SARS-CoV-2 infection, taking into account the age of the person being screened given different criteria for people under 18 years old. If a Visitor answers affirmatively to any screening question, they should, if appropriate, be referred for testing and directed to the DPH website with information about Health Officer directives on isolation and quarantine and explanatory material in multiple languages, available online at https://www.sfcdcp.org/covid19. Screening may be done by phone, verbally in person ensuring at least six feet of physical distance, or using other methods such as text or email. It is up to the Residential Facility, at the discretion of the Administrator or designee, to decide which method(s) for screening work best for the context. A Residential Facility may use temperature checks consistent with DPH guidelines, and it must conduct temperature checks for Outdoor Visitation. 9. Other COVID-19 Related Protocols. The following sections list additional COVID19 related protocols aimed at protecting residents, staff, and Visitors. 10. Non-Essential Resident Movement is Discouraged. Each Residential Facility must discourage Non-Essential Resident Movement, as defined in Section 18.c below, onto and off of Residential Facility Premises where feasible. Whenever a Residential Facility resident leaves the Residential Facility Premises, the resident is ordered to comply with Social Distancing Requirements listed in Section 8.o of the Stay-SaferAt-Home Order. At the time this Order was issued, the Social Distancing Requirements are: a. Maintaining at least six-foot social distancing from individuals who are not part of the same Household; b. Frequently washing hands with soap and water for at least 20 seconds, or using hand sanitizer that is recognized by the Centers for Disease Control and Prevention as effective in combatting COVID-19; c. Covering coughs and sneezes with a tissue or fabric or, if not possible, into the sleeve or elbow (but not into hands); 13 City and County of San Francisco Department of Public Health Order of the Health Officer ORDER OF THE HEALTH OFFICER No. C19-03b d. Wearing a face covering when out in public, consistent with the orders or guidance of the Health Officer; and e. Avoiding all social interaction outside the Household when sick with a fever, cough, or other COVID-19 symptoms. 11. Face Coverings. In general, all residents, staff, and Visitors must comply with Order No. C19-12c of the Health Officer, issued on July 22, 2020 (the “Face Covering Order”), including as that order is revised in the future. Residents, staff, and Visitors must also comply with any other requirements of the Residential Facility regarding wearing a mask or Face Covering or other Personal Protective Equipment (“PPE”). In addition to the exceptions to wearing a Face Covering listed in the Face Covering Order, a Face Covering is not required for any resident who, on account of dementia, grave mental illness, fear of/concern for suffocation, inability to remove a Face Covering, inability to call for help, physician order, or other circumstance should not wear a Face Covering. The Residential Facility must provide a Face Covering or other mask to any resident or Visitor on request. The Face Covering Order and this Order allow Residential Facilities to require and provide coverings that offer added protection such as an isolation mask or personal protective equipment (“PPE”), as appropriate in the circumstances. 12. Written COVID-19 Plan Requirement. Each Residential Facility must update and continue to implement the written plan that was originally required by the prior version of this Order (the “COVID-19 Plan”). This Order does not require a Residential Facility to create any new documentation if it already has written policies or other written guidance that address the requirements for the COVID-19 Plan. The Residential Facility’s existing COVID-19 Plan may be used while a new version is prepared, and the COVID-19 Plan should be updated no later than September 15, 2020. The plan must comply with applicable guidance from the DPH regarding the screening of patients, personnel, and visitors for signs of COVID-19 or other illnesses. The COVID-19 Plan must also address other applicable COVID19-related guidance, including steps to reduce the risk of COVID-19 transmission by authorized Visitors and Non-Essential Persons such as through hand washing, use of Face Coverings, imposition of the Social Distancing Requirements listed in Section 8.o of the Stay-Safe-At-Home Order, and limiting the duration of visits, as appropriate. Nothing in this Order prohibits a Residential Facility from taking steps more protective against transmission of COVID-19 than guidance provided by the CDC, CDPH, and DPH in its plan. Each Residential Facility must update its COVID-19 Plan when appropriate under new COVID-19 recommendations or requirements issued by DPH or as otherwise required by law. See the COVID-19 Guidance (discussed in Section 15 below) for more information about the COVID19 Plan. 14 City and County of San Francisco Department of Public Health Order of the Health Officer ORDER OF THE HEALTH OFFICER No. C19-03b 13. Staff Screening. Each Residential Facility’s COIVD-19 Plan must also include a requirement that any employee or other staff member who is sick or does not pass the required screening must be immediately sent home and not return to work until they can do so safely under DPH guidance or authorized to return by a physician. If a Residential Facility is unable to immediately send home any such employee or staff member, the Residential Facility must (1) prevent that staff member from engaging in any resident care or contact and (2) immediately notify its respective licensing entity and seek guidance from that entity. 14. Staff and Resident Testing. On May 7, 2020, the Health Officer issued Order No. C19-13 regarding testing and infection control practices at congregate living facilities in the City, including each Residential Facility. Each Residential Facility is required to continue to comply with that order. 15. COVID-19 Guidance. Attached to this Order as Appendix B is written guidance to Residential Facilities (“COVID-19 Guidance”) issued by the Health Officer. The Health Officer or designee may revise the COVID-19 Guidance in writing from time to time. Each Residential Facility must follow the COVID-19 Guidance. 16. Non-Compliance. If any Visitor or Non-Essential Person refuses to comply with this Order, then the Residential Facility may contact the San Francisco Police Department to request assistance in enforcing this Order. The Residential Facility shall take whatever steps are possible within the bounds of the law to protect residents from any such Visitor or person who refuses to comply with this Order. For example, a Residential Facility should contact facility security and ask the unauthorized visitor or person to comply with conditions of visitation imposed by the Residential Facility. Even if a Visitor or Non-Essential Person otherwise complies with the facility’s visitation protocols as outlined in this paragraph, they are still in violation of this Order if their presence is not an Allowed Visitation or Necessary Visitation under this Order. 17. No Restriction on First Responders, Others. This Order does not restrict first responder access to Residential Facility Premises during an emergency. Further, this Order does not restrict state or federal officers, investigators, or medical or law enforcement personnel from carrying out their lawful duties on Residential Facility Premises. Persons other than first responders allowed access under this paragraph must comply with all conditions of visitation imposed by the Residential Facility at the time of entry or access to the Residential Facility Premises when feasible. 18. Definitions: For the purposes of this Order, the following initially capitalized terms have the meanings given below: a. “Visitors” are people who come onsite to a Residential Facility to meet with a resident who are not staff of the facility. This term includes family members 15 City and County of San Francisco Department of Public Health Order of the Health Officer ORDER OF THE HEALTH OFFICER No. C19-03b and loved ones of residents and those who have legal authority to make healthcare or other legal decisions for a resident. The Ombudsperson is an authorized visitor and is not included in this term, but the Ombudsperson must still follow all conditions of visitation imposed by the Residential Facility and should also try to avoid non-essential visits. b. “Non-Essential Personnel” are employees, contractors, or others who provide services onsite at a Residential Facility but who do not perform treatment, maintenance, support, or administrative tasks deemed essential to the healthcare mission of the Residential Facility. Refer to the COVID-19 Guidance for more information. c. “Non-Essential Resident Movement” means travel off or onto Residential Facility Premises by a resident other than for specific treatment or pressing legal purposes as described more fully in the COVID-19 Guidance. d. “Premises” includes without limitation the buildings, grounds, facilities, driveways, parking areas, and public spaces within the legal boundaries of each Residential Facility listed in Section 20 below. e. “COVID-19 Symptom” means a symptom consistent with SARS-CoV-2 infection. At the time this Order is issued, that list includes for individuals 18 years or older any of the following symptoms which is not explained by another condition or diagnosis: temperature greater than 100.4F (38.0C); cough; sore throat; shortness of breath; chills; headache; body aches; fatigue; loss of smell or taste; diarrhea; runny nose; nasal congestion; or other symptoms if there is associated clinical concern for COVID-19. For those younger than 18 years, “COVID-19 Symptom” means any of the following symptoms which is not explained by another condition or diagnosis: temperature greater than 100.4F (38.0C); sore throat; new uncontrolled cough that causes difficulty breathing (for youth with chronic allergic/asthmatic cough, a change in their cough from baseline); diarrhea, vomiting, or abdominal pain; new onset of severe headache, especially with a fever; or other symptoms if there is associated clinical concern for COVID19. 19. Licensing Entity Notification. Each Residential Facility must within 12 hours of receipt of this Order notify its respective licensing entity (whether the California Department of Public Health or otherwise) of the existence of this Order regarding the Residential Facility. And as noted in Section 5 above, if a facility is unable to offer any form of Allowed Visitation (other than temporarily based on short-term staffing or other conditions), it must notify CDPH with an explanation of why it is unable to offer such visitation. 16 City and County of San Francisco Department of Public Health Order of the Health Officer ORDER OF THE HEALTH OFFICER No. C19-03b 20. List of Residential Facilities. This Order applies to each facility listed below (each a Residential Facility): Residential Facility Name Lawton Skilled Nursing & Rehabilitation Center San Francisco Health Care Central Gardens Post Acute San Francisco Post Acute Hayes Convalescent Hospital Heritage on The Marina The Avenues Transitional Care Center Laurel Heights Community Care Pacific Heights Transitional Care Center Tunnell Skilled Nursing & Rehabilitation Center Sequoias San Francisco Convalescent Hospital Sheffield Convalescent Hospital St. Anne's Home Victorian Post Acute California Pacific Medical Center - Davies Campus Hospital D/P SNF Jewish Home & Rehab Center D/P SNF San Francisco Towers Kentfield San Francisco Hospital Street Address 1575 7th Ave 1477 Grove St 1355 Ellis St 5767 Mission St 1250 Hayes St 3400 Laguna St 2043 19th Ave 2740 California St 2707 Pine St 1359 Pine St 1400 Geary Blvd 1133 S Van Ness Ave 300 Lake St 2121 Pine St 601 Duboce Ave 302 Silver Ave 1661 Pine St 450 Stanyan St, 6th Floor ZIP 94122 94117 94115 94112 94117 94123 94116 94115 94115 94109 94109 94110 94118 94115 94117 94112 94109 94117 *Note: Laguna Honda Hospital and ZSFG D/P SNF are covered under a separate order 21. Complaints. A Residential Facility resident or the resident’s authorized lawful representative may contact a representative of the Residential Facility to seek clarification of any part of this Order by contacting the Administrator of the facility. If a resident or the resident’s authorized lawful representative objects to the appropriateness of the limitation of access contained in this Order, the resident or lawful authorized representative must first raise their concern with the Residential Facility at issue. The Residential Facility is ordered to respond to the concern within 2 business days. 22. Continuing Severe Health and Safety Risk Posed by COVID-19. This Order is issued based on the need for continued protection of all Residential Facility Visitors, residents, and staff in the City. Due to the COVID-19 pandemic, there is a public 17 City and County of San Francisco Department of Public Health Order of the Health Officer ORDER OF THE HEALTH OFFICER No. C19-03b health emergency throughout the City. Residents at Residential Facilities are among the most vulnerable and most likely to face serious outcomes, including death, from infection by SARS-CoV-2. There are currently only limited treatments and not approved vaccine for COVID-19, and there is a high risk of infection from asymptomatic and pre-symptomatic people who have the virus. Due to the length of time during which people with the virus can unknowingly infect others, it is imperative that all appropriate steps be taken to protect residents and staff who deal with residents from infection. Limiting visitors and requiring the other safety protections included in this Order will thereby slow virus transmission as much as possible in order to protect the most vulnerable, prevent infections and serious illness and death, and prevent the healthcare system from being overwhelmed. 23. Cases, Hospitalizations, and Deaths. As of September 1, 2020, there are 9,755 confirmed cases of COVID-19 in the City (up from 37 on March 16, 2020, the day before the first shelter-in-place order in the City went into effect) as well as at least 84 deaths (up from 1 death on March 17, 2020). This information, as well as information regarding hospitalizations and hospital capacity, is regularly updated on the San Francisco Department of Public Health’s website at https://data.sfgov.org/stories/s/fjki-2fab. 24. Incorporation of State and Local Emergency Proclamations and State Health Orders. a. State and Local Emergency Proclamations. This Order is issued in accordance with, and incorporates by reference, the March 4, 2020 Proclamation of a State of Emergency issued by Governor Gavin Newsom, the March 12, 2020 Executive Order (Executive Order N-25-20) issued by Governor Gavin Newsom, the February 25, 2020 Proclamation by the Mayor Declaring the Existence of a Local Emergency issued by Mayor London Breed, as supplemented on March 11, 2020, the March 6, 2020 Declaration of Local Health Emergency Regarding Novel Coronavirus 2019 (COVID-19) issued by the Health Officer, and guidance issued by the California Department of Public Health, as each of them have been and may be supplemented. b. State Health Orders. This Order is also issued in light of the March 19, 2020 Order of the State Public Health Officer (the “State Shelter Order”), which set baseline statewide restrictions on non-residential Business activities, effective until further notice, the Governor’s March 19, 2020 Executive Order N-33-20 directing California residents to follow the State Shelter Order, and the July 13, 2020 Order of the State Public Health Officer. The May 4, 2020 Executive Order issued by Governor Newsom and May 7, 2020 Order of the State Public Health Officer permit certain Businesses to reopen if a local health officer believes the conditions in that jurisdictions warrant it, 18 City and County of San Francisco Department of Public Health Order of the Health Officer ORDER OF THE HEALTH OFFICER No. C19-03b but expressly acknowledge the authority of local health officers to establish and implement public health measures within their respective jurisdictions that are more restrictive than those implemented by the State Public Health Officer. Also on June 18, 2020, the State Department of Public Health issued guidance for the use of face coverings, requiring all people in the State to wear face coverings in certain high-risk situations, subject to limited exceptions. 25. Effective Date. This Order becomes effective at 9 a.m. on Saturday, September 5, 2020, and will continue to be in effect until it is extended, rescinded, superseded, or amended in writing by the Health Officer. Effective as of 9 a.m. on September 5, 2020, this Order revises and replaces Health Officer Order No. C19-03, issued March 10, 2020. 26. Reporting Violations. Any person who believes this Order is being violated may contact 3-1-1 or go to www.sf.gov/report-health-order-violation to provide information about the alleged violation. 27. Copies and Notice. Each Residential Facility must promptly provide notice of this Order as follows: (1) by posting this Order on the Residential Facility website (if any); (2) by posting this Order at all entrances to the Residential Facility; (3) by providing a summary of this Order to each Residential Facility resident, indicating how the resident can obtain a full copy; (4) by providing a summary of this Order to any authorized decision maker for each Residential Facility resident if not the resident, including any conservator, indicating how the decision maker can obtain a full copy; (5) by providing this Order to the Residential Facility Ombudsperson (if any); and (6) by giving a copy to anyone who visits the Residential Facility or who contacts the Residential Facility seeking to visit. The City must promptly provide copies of this Order as follows: (1) by posting on the Department of Public Health website at www.sfdph.org/healthorders; (2) by posting at City Hall, located at 1 Dr. Carlton B. Goodlett Pl., San Francisco, CA 94102; and (3) by providing to any member of the public requesting a copy. 28. Severability. If any provision of this Order or its application to any person or circumstance is held to be invalid, then the remainder of the Order, including the application of such part or provision to other people or circumstances, shall not be affected and shall continue in full force and effect. To this end, the provisions of this Order are severable. 29. Interpretation. All provisions of this Order must be interpreted to effectuate the intent of this Order as described in Section 1 above. The summary at the beginning of this Order as well as the headings and subheadings of sections contained in this Order are for convenience only and may not be used to interpret this Order; in the 19 City and County of San Francisco Department of Public Health Order of the Health Officer ORDER OF THE HEALTH OFFICER No. C19-03b event of any inconsistency between the summary, headings, or subheadings and the text of this Order, the text will control. Certain initially capitalized terms used in this Order have the meanings given them in this Order. IT IS SO ORDERED: Tomás J. Aragón, MD, DrPH, Health Officer of the City and County of San Francisco Date: September 4, 2020 20 ORDER OF THE HEALTH OFFICER No. C19‐03b  Appendix A – Allowed Visitation Summary    Note:  This document provides a summary for convenience of the requirements for Allowed  Visitation under Section 5 of the Order.  Each Residential Facility must comply with all requirements  of the Order, regardless of what is listed below.      FACILITY VISITATION PREREQUISITES   VISITATION TYPE  PREREQUISITES    Outdoor Visits    Facility Window Visits with an Open  Window     1. No visitation for residents with symptoms, in isolation or COVID+ and  quarantine    2.  Absence of any new COVID‐19 cases in the facility for 14 days, either  residents or staff, AND not currently in the surveillance period for an active  outbreak      Vehicle Visits with Open Windows  Facility Window Visit with a Closed  Window /  Vehicle Visits with Closed Facility  Windows   Visitor(s) do not walk through the facility   (Note that items 1. and 2. above do not apply for closed‐window visits)    In the event of a new COVID‐19 case at the facility,   take the following actions until the following visitation prerequisites are met:  VISITATION TYPE  ACTION    Outdoor Visits  Suspend/Postpone       For facilities with multiple units/floors, contact the DPH / OMG1 to determine if  Facility Window Visits with an Open  Window   the facility can safely cohort to allow visitation for residents in non‐outbreak units.  Vehicle Visits with Open Windows     Facility Window Visit with a Closed  Window /  Allow as long as the visitor(s) do not walk through the facility  Vehicle Visits with Closed Facility  Windows           1  ORDER OF THE HEALTH OFFICER No. C19‐03b  Appendix A – Allowed Visitation Summary    For Outdoor Visits, facilities must comply with the following parameters:  VISITATION TYPE  Outdoor Visits    Definition: Visitor and    Resident are both in an  outdoor setting             PARAMETERS  Visits must be supervised by facility staff at all times.  Visitation in outdoor settings only.  o If weather does not permit, provide window or vehicle visits.  Visits must be scheduled in advance; facility can determine visiting hours.  Visitor(s) must wear masks. Residents must wear masks or other face coverings (as  tolerated). 2   6‐feet or more physical distancing (no physical touching between resident and  visitor such as hugging, hand‐shaking, etc.) It is the facility’s responsibility to  monitor and ensure compliance.  It is required to put up signs and clearly mark  areas to prevent visitor(s) groups from being too close to each other.  No more than 4 visitors from the same household. If visitors are from different  households, the group should be limited to 2 visitors. Visitation group size can be  determined based on facility space to allow for proper distancing and safety.  Visitation by children is left to the discretion of the facility.  If children are allowed  to visit, all visitors ages 2+ should wear a face covering, and children must be under  supervision at all times.  Screening should take into account age‐specific symptoms.  Screen visitors for symptoms and related issues and conduct temperature check  prior to visit.  Perform hand hygiene in accordance with CDC guidelines (provide supplies as  needed).  Routinely clean and disinfect all frequently touched surfaces.  Sharing items, including food, drinks, or utensils, during any in‐person visits is not  permitted.  If gifts are permitted under a separate policy, they must be approved by  facility staff and processed by facility staff, providing an opportunity for disinfection  and sanitization.  Items or gifts may not be exchanged directly during the visit.   Visits must not exceed 1 hour and may be shorter if needed to accommodate  residents while assuring compliance with visitation rules.  Whenever possible, visitation should take place without visitors walking through  the facility or walking the shortest route through the facility.            2  ORDER OF THE HEALTH OFFICER No. C19‐03b  Appendix A – Allowed Visitation Summary    For Facility Window Visits, facilities must comply with the following parameters:  VISITATION TYPE  For All window visits:              Facility Window Visits  with an Open Window     Definition: Visitor and     Resident are separated by  and open window with the  Resident on the Facility side  of a window and Visitor(s)  outside on the other side  Facility Window Visit  with a Closed Window    Definition: Visitor and   PARAMETERS  Visits must be supervised by facility staff at all times  Visits must be scheduled in advance; facility can determine visiting hours.  No more than 4 visitors from the same household. If visitors are from different  households, the group should be limited to 2 visitors. Visitation group size can be  determined based on facility space to allow for proper distancing and safety.  Screen visitors for symptoms and related issues prior to visit.  Facility should have a phone available to speak to resident at a safe distance.  If the resident must be taken to any of the designated areas, the resident must  wear a mask (as tolerated)2 for that journey.  Whenever possible, visitation should take place without visitor(s) walking through  the facility or walking the shortest route through the facility.  Sharing items, including food, drinks, or utensils, during any in‐person visits is not  permitted.  If gifts are permitted under a separate policy, they must be approved by  facility staff and processed by facility staff, providing an opportunity for disinfection  and sanitization.  Items or gifts may not be exchanged directly during the visit.   Routinely clean and disinfect all frequently touched surfaces.  Visits must not exceed 1 hour and may be shorter if needed to accommodate  residents while assuring compliance with visitation rules.  Visitation by children is left to the discretion of the facility.  If children are allowed  to visit, all visitors ages 2+ should wear a face covering, and children must be under  supervision at all times.  Screening should take into account age‐specific symptoms.    Resident must stay at least 3 feet back from the window and wear a mask (as  tolerated). 2  Visitor(s) must stay at least 3 feet back from the window and wear a mask.  Facility should ensure that visitors seeing different residents can also keep at least 6  feet apart (limit crowding) and farther if needed so people can hear without  shouting.  It is required to put up signs and clearly mark areas to prevent visitor(s)  groups from being too close to each other.    If the visitor(s) is in an area were other people will be passing, the visitor(s) must  wear masks.  Resident are separated by a  Window.  At all times, the  facility window must remain  closed so no air flow is  exchanged          3  ORDER OF THE HEALTH OFFICER No. C19‐03b  Appendix A – Allowed Visitation Summary    For Vehicle Visits, facilities must comply with the following parameters:  VISITATION TYPE  For All Vehicle Visits:            Vehicle Visits with  Open Windows    Definition: Visitor(s), in a    vehicle, and Resident are  separated by at least 6 feet  of distance where the  Resident is in either an  outdoor space or in the  Facility behind an open  window     Vehicle Visits with  Closed Facility  Windows    Definition: Visitor(s), in a  PARAMETERS  Visits to be supervised by facility staff at all times.  Visits must be scheduled in advance; facility can determine visiting hours.  Screen visitors for symptoms and related issues prior to visit.  Facility should have a phone available to speak to resident at a safe distance.  If the resident must be taken to any of the designated areas, the resident must  wear a mask (as tolerated)* for that journey.  Sharing items, including food, drinks, or utensils, during any in‐person visits is not  permitted.  If gifts are permitted under a separate policy, they must be approved by  facility staff and processed by facility staff, providing an opportunity for disinfection  and sanitization.  Items or gifts may not be exchanged directly during the visit.   Routinely clean and disinfect all frequently touched surfaces.  Visits must not exceed 1 hour and may be shorter if needed to accommodate  residents while assuring compliance with visitation rules.  Resident should stay at least 6 feet back from the vehicle window and wear a mask  (as tolerated). 2  Visitor(s) must wear a mask.  If there is a pull‐in area for vehicle visits, the visits must be scheduled to prevent  crowding and keep at least 6 feet between residents.  To reduce air flow to the resident, if possible, keep vehicle’s window closest to the  resident closed.   If the visitor(s) is in an area were other people will be passing, the visitor(s) must  wear masks in the vehicle.  vehicle, and Resident are  separated by a Closed  Facility Window.  At all  times, the facility window  must remain closed so no air  flow is exchanged.      1  Contact DPH Outbreak Management Group (OMG) with any specific questions for their sites and guidance.  Call   415‐554‐2830, select Option 1, and then follow the prompts for Senior Care Facilities.  See Section 6 of the Order for  details.    2  Requirements for masks or face coverings are relaxed for residents as follows and for related/similar issues:  a  diagnosis of dementia or grave mental illness; fear of/concern for suffocation, inability to remove or call for help OR  ordered by physician.  See Section 11 of the Order for details.      4  City and County of San Francisco Department of Public Health Order of the Health Officer APPENDIX B: WRITTEN GUIDANCE REGARDING COMPLIANCE WITH HEALTH OFFICER ORDER No. C19-03b DATE ORDER ISSUED: September 4, 2020 This information (the “COVID-19 Guidance”) is meant to help each Residential Facility when implementing the Order to which it is attached. This document uses the terms defined in the Order. 1. For purposes of the Order, the term “Administrator” means the administrator of a Residential Facility or the administrator’s designee. 2. The Order does not prohibit a Residential Facility from being more restrictive in its operations and practices than is outlined in the Order. The Order also does not require allowing visitation when not otherwise required by applicable laws or regulations. 3. Guidance regarding Section 12 (the COVID-19 Plan): The Order requires the Residential Facility to create a COVID-19 Plan that addresses issues including: 1) screening of residents, staff, and Visitors for COVID-19 Symptoms or other illness; 2) conditions of visitation imposed by the Residential Facility at the time of entry or access to the Premises for authorized visitors that reduce the risk of infection, such as thorough hand washing, appropriate use of Personal Protective Equipment (PPE), maintaining at least six feet distance from other people, and limiting the duration of visits, as appropriate; 3) sending sick employees home immediately; 4) notifying DPH and other regulators of any positive SARS-CoV-2 result for a resident or staff member, including as required by law; and 5) other CDC or CDPH requirements. Note that the Order does not require a Residential Facility to create any new documentation if it already has policies or other guidance that address the requirements for the COVID-19 Plan. The COVID-19 Plan should also address how the facility can reduce the risk of unnecessary exposure as outlined in the San Francisco Department of Public Health Social Distancing Protocol, attached as Appendix A to Health Officer Order No. C19-07h (or as that order is revised in the future). For example, the facility should avoid large inperson gatherings of residents or staff, instead holding smaller gatherings that still meet the facility’s mission and needs (e.g., substituting unit-based activities for a facility-wide bingo event). Similarly, postponing large staff meetings or having meetings occur by phone can help when feasible. Additionally, there may be areas that warrant limitations that are not normally in place. A Residential Facility may have a cafeteria or other concession that is normally available to residents, essential employees, other employees (such as others who share the building but are not associated with the healthcare mission of the facility), and Visitors. While this Order is in effect, the Residential Facility should consider whether a restriction on such use makes sense. One option might be to limit cafeteria visits to residents and essential staff and temporarily block other employees and Visitors from that area. 1 City and County of San Francisco Department of Public Health Order of the Health Officer WRITTEN GUIDANCE REGARDING COMPLIANCE WITH HEALTH OFFICER ORDER No. C19-03b If the facility had plans to have vendors come onsite for meetings or to show sample products, those meetings should be conducted via remote communication, occur at another site that does not include a vulnerable population, or be postponed until after this emergency situation if possible. 4. Guidance regarding Section 4 (efforts to facilitate contact that is not in-person): The Order requires the Residential Facility to make reasonable efforts to facilitate contact that is not in person between a Visitor or Non-Essential Personnel and a resident. Such efforts include using technology to facilitate a remote connection with the resident when possible and would include telephone calls, telephone conferences involving multiple people, and video conferences using appropriate technology. Efforts are not reasonable if they interfere with the Residential Facility’s healthcare mission or if they are not available or are cost prohibitive. The Residential Facility is encouraged to be creative in trying to facilitate contact that is not in-person so long as it complies with its other legal and regulatory obligations. 5. Guidance regarding Section 7 (Necessary Visitation): The term Necessary Visitation refers to a visit or contact that is based on urgent health, legal, or other issues that cannot wait until later. Nothing in the Order limits the standard healthcare that the Residential Facility provides to a resident. When medical care is appropriate or required, it is by definition permitted under the Order. Necessary Visitation refers to other types of visits or contact that are time-sensitive or critical. For example, a resident may be in the end stages of life. In that instance, family or loved ones should be allowed to be with the resident unless doing so would interfere with the Residential Facility’s mission in light of the current emergency, such as during a serious outbreak of cases. Another example would be a resident who is updating their will or other legal papers and an in-person meeting with the lawyer or family members or a notary is required, again unless doing so would interfere with the Residential Facility’s mission. But, a meeting with a lawyer to discuss future changes or other, non-urgent issues should generally be postponed or conducted via telephone or other means. Anyone who is legally authorized to make decisions for the resident, whether by operation of a durable power of attorney or public or private conservatorship, must be given special consideration, especially if they need to meet in person with the resident to fulfill their role. This distinction is in place because decisions regarding care when there is a surrogate decision maker should not be delayed when in-person contact is needed, whereas visits by other family or loved ones are important but may not be time-sensitive. But such authorized decision-makers should be encouraged to use alternative methods of contacting the resident when possible in order to avoid exposing the resident and others. Also, Necessary Visitation should not be granted for routine visits by decision makers, family, or loved ones, even if the resident very much looks forward to the visit or the visitor has a strong desire for the visit. Such routine visits put all residents at risk at this 2 City and County of San Francisco Department of Public Health Order of the Health Officer WRITTEN GUIDANCE REGARDING COMPLIANCE WITH HEALTH OFFICER ORDER No. C19-03b time and may only occur as Allowed Visitation. But if a family member or loved one plays an essential role in providing care to a resident, without which the resident will suffer medical or clinical harm, Necessary Visitation may be appropriate. There may be other unique situations that justify a Necessary Visitation based on the context. And as the situation evolves, the Residential Facility may need to restrict Necessary Visitation. This Order is intended to give the Administrator flexibility in making that determination so long as the decision is in line with the Order and this COVID-19 Guidance. The Administrator should not authorize Necessary Visitation for all or a majority of residents as that would likely reflect a violation of the intent of the Order to protect all residents from the risks of non-essential exposure to COVID-19. All visits allowed as Necessary Visitation must occur subject to all conditions of visitation imposed by the Residential Facility at the time of entry or access to the Premises. 6. Guidance regarding Sections 3 and 18.b (Non-Essential Personnel): The Order defines Non-Essential Personnel as employees, contractors, or others who provide services onsite at a Residential Facility but who do not perform treatment, maintenance, support, or administrative tasks deemed essential to the healthcare mission of the Residential Facility. This term also includes employees of the Residential Facility or its vendors (and their employees) who are not needed in the short term for the facility to perform its healthcare mission. For example, a vendor that makes deliveries of large bottled water refill jugs is likely not essential. However, the facility should work to see if there are ways to permit delivery, such as on a loading dock, which would eliminate the need in the short term for someone to make visits all across the facility. This Order grants the Administrator authority to make judgment calls about how best to ensure the facility is able to operate during this emergency situation. 7. Guidance regarding Section 18.c (Non-Essential Resident Movement): The Order defines Non-Essential Resident Movement as travel off or onto Residential Facility Premises by a resident other than for specific treatment or pressing legal purposes. This is contrasted with situations when a resident leaves the facility for health-related purposes or as required by law, such as for a meeting or service mandated by a court. The goal of the Order is to encourage residents to limit Non-Essential Resident Movement. * * Dated: September 4, 2020 3 *