Variability in State Regulations Pertaining to Infection Control and Pandemic Response in US Assisted Living Communities

At the end of 2019, international attention was drawn to an outbreak of zoonotic coronavirus SARS-CoV-2, formally named COVID-19, in Wuhan, China.¹ The World Health Organization officially declared the outbreak a global pandemic on March 11, 2020, with the United States recording >1600 confirmed and presumptive travel-related and community-acquired cases at that time.^{1 , 2} As of April 10, 2020, all 50 US states and the District of Columbia, have reported cases, with the total number of US cases now totaling >400,000.² Seattle, WA, is the US epicenter, with nursing facilities experiencing the greatest number of fatalities.³ Because of the communal living environments of long-term care settings, as well as the majority resident population aged 65 years and older with underlying health conditions, long-term care settings are at a high risk of sustained COVID-19 transmission.³ Nursing homes have federally regulated infection prevention and control guidelines and are surveyed annually for regulatory adherence. However, states have primary responsibility for licensing and oversight of residential care/assisted living (RC/AL) communities, a setting where 82.4% of residents are aged ≥75 years.⁴ It remains unclear if and how states require RC/AL communities to mitigate, prepare, and respond to infection among their residents, a group particularly vulnerable to the effects of the current COVID-19 pandemic.

Methods

Qualitative thematic coding was used to review AL regulations (current through 2018) for all 50 states and the District of Columbia. Key search terms included epidemic, pandemic, and infection control. Two graduate student researchers with experience in qualitative coding used an existing data set, curated as part of a larger research study of RC/AL regulation. Coding and analysis were done using ATLAS.ti, version 8.4.24.0 (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany), and R software, 2019 (R Foundation for Statistical Computing, Vienna, Austria).^{5 , 6}

Results

We identified 31 states describing infection control policies (Table 1 ). Infection control policies include the routine practice of universal or standard precautions, guidelines for contact with blood or other bodily fluids, or reportable disease guidelines. Some, though not all states, require staff to be trained in infection control. Though the level of detail in the regulation text varies, a total of 32 total states list or describe infection control as a training component (Table 1). Ten states include language surrounding epidemics, primarily regarding reportable disease and requirements for reporting to local Public Health departments, and 2 (MA and OR) describe pandemic emergency preparedness (Table 1). Despite current state and national responses to COVID-19 in long-term care settings including the exclusion of nonessential visitors, only 6 states (CO, IL, IN, KS, MA and ND) directly reference general resident isolation practices for communicable diseases within their infection control policies.

Table 1.

Findings From State Policy Review

State	Infection Control Policy (n = 31)	Infection Control Referenced in Staff Training (n = 32)	Epidemic (n = l0)	Pandemic (n = 2)
AL
AK		X
AZ		X
AR		X
CA			X
CO	X		X
CT
DC		X
DE	X		X
FL	X	X
GA	X	X
HI	X	X
ID	X	X
IL	X	X
IN	X	X	X
IA	X	X
KS	X	X
KY
LA	X	X
ME		X
MD		X
MA	X	X	X	X
MI
MN	X
MS
MO	X	X	X
MT	X
NE		X
NV
NH	X	X
NJ	X	X
NM		X
NY
NC	X	X
ND	X	X
OH	X
OK
OR		X	X	X
PA		X
RI	X	X
SC	X	X	X
SD	X	X
TN	X	X
TX	X
UT	X		X
VT
VA	X	X
WA	X
WV	X	X	X
WI	X
WY	X	X

An “X” denotes the presence of the language in the administrative code.

Implications for Policy

Based on our review of 31 states with infection and epidemic prevention regulations, states take 2 approaches: (1) requiring communities to develop infection control policies, or (2) requiring facility compliance with reporting and public health cooperation in the case of an epidemic. In addition, we identified 13 states (CO, GA, IA, IN, MA, ND, NH, NJ, SD, UT, VA, WA, WI) that require more robust policies and procedures, operationalized via an infection control program. For example, in New Hampshire, an appointed individual is tasked with developing both an infection control program and educational plan (N.H. Admin. Rules, He-P 804.22). Washington's AL administrative rules for “infection control” (WAC 388-78A-2610) includes 5 components: a system to identify and manage infections, staff-specific policies, provision of supplies (eg, protective clothing), current infection control standards, and reporting requirements.

Although most US states have regulations requiring infection control policies and procedures for RC/ALs, they range in the level of detail and requirements. There is potential for RC/AL communities to have confusion during epidemics/pandemics in translating these regulations into practice without adequate support and resources. In addition, the sociocultural model of AL emphasizes a homelike, noninstitutional setting and practices. This model, associated with resident quality of life, can conflict with standard clinical and public health practices in hospitals in nursing homes, such as wearing medical products (eg, gloves, respirators, scrubs).^{7 , 8} Therefore, RC/AL communities may face tension in providing an environment synonymous with the sociocultural model of RC/AL, while ensuring resident safety during outbreaks. The effect of varying infection control regulations on RC/AL communities’ practices and ultimately residents is unknown; however, these relationships will be an area of focus as the COVID-19 pandemic continues to develop and adversely impacts older adults residing in these settings.