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New masking requirements for skilled nursing facilities set by two California county health departments underscore the piecemeal nature of the nation’s COVID-19 mitigation policies, according to some stakeholders.

Contra Costa and Alameda counties in the San Francisco Bay Area each have ordered staff members in SNFs to continue to wear masks in the workplace. The orders go into effect on Monday (April 3), just as the state’s COVID-19 masking order for healthcare settings expires.

“Local county public health departments can implement stricter guidance as deemed appropriate,” the California Association of Health Facilities explained Wednesday. The organization is not aware of other counties that plan a similar course of action at this time, a representative said in an email to McKnight’s Long-Term Care News

Los Angeles county also recently updated its mask guidance, requiring continued use of masks in healthcare settings, including long-term care settings and other senior care facilities.

No states have kept general pandemic mask orders since federal health officials retired much of their stringent pandemic-era guidance in September. But several states continue to require face coverings in high-risk settings, such as nursing homes, hospitals and shelters, according to an AARP list of COVID-19-related restrictions updated March 21. These include Connecticut, Delaware, the District of Columbia, Massachusetts, New Mexico, North Carolina and Puerto Rico. Colorado requires staff and visitors in long-term care facilities to mask up at times of high community transmission. In Washington (like California), a mask order that includes long-term care facilities is scheduled to end April 3, AARP reported.

Long-term care industry and local clinician opinions regarding the California counties’ new orders are varied and nuanced. But generally, they lean toward supporting enforced masking and other COVID-19 mitigation measures in nursing facilities.

LeadingAge has strongly supported member advocacy efforts to lift restrictions that create an undue burden on resident quality of life. Its California members have opposed requirements that staff and visitors be masked in senior living communities, Meredith Chillemi, director of regulatory affairs, LeadingAge California, told McKnight’s.

But “members who provide care in clinical settings, such as the nursing home level of care, are continuing to choose masking of staff and visitors,” she noted.

Clear guidance needed

At least one influential California long-term care clinician lamented the random nature of local rule-setting, while supporting the county health departments’ decisions to take charge of infection control policy on behalf of SNF residents. 

With many Americans vaccinated, COVID-19 is now more like a really bad flu for the general public, said Michael R. Wasserman, MD, chair of the public policy committee for the California Association of Long Term Care Medicine.

“But a really bad flu still kills nursing home residents,” he told McKnight’s in a telephone interview. “As a clinician, I am very supportive of continuing masking requirements in nursing homes. The problem is there are no requirements on the federal level.”

Leaving it up to individual facilities to gauge the need for masking and other mitigation measures doesn’t work, and “nursing home residents and staff have suffered from needing clarity” since the pandemic measures were rolled back, Wasserman added. “You can’t just say, ‘This is our recommendation, think about it.’ [Nursing facilities] need clear guidance and direction.”

“For the time being, if a county has decided to keep requiring masks, I’ve got no problem with that whatsoever,” he said.

Concerned about the vulnerable

In their stated reasons for implementing new masking rules, county health officials said they were focused on the vulnerability of SNF residents.

“Alameda County is moving cautiously with our skilled nursing facilities because they serve a large and highly vulnerable population of generally older adults with complex medical conditions,” County Health Officer Nicholas Moss, MD, said in a statement Monday. 

Alameda County has 66 licensed skilled nursing facilities with capacity for more than 5,400 residents. COVID-19 has caused or contributed to the deaths of more than 2,400 Alameda County residents to date, and most of those deaths were older adults, according to Moss.

“Some of the most devastating impacts of the pandemic occurred among residents of skilled nursing facilities,” he added.

There are 30 SNFs in Contra Costa County. Its order will not apply to assisted living facilities, residential-care facilities or board-and-care homes, officials noted Monday, but masking remains “highly recommended” in those settings.