Included within the CDC guidance are links to other information relevant to long term care providers, including guidance for long term care facilities that offer medical services (i.e. nursing homes, skilled nursing facilities, assisted living facilities, and adult daycare programs), and a checklist for such provider types which the CDC notes can be adapted to meet the needs of retirement communities and ILFs, as well as other information relevant to older adults with serious chronic medical conditions and community-based organizations

This interim guidance is very helpful as non-health care, long term care providers across the country, including senior housing, HUD 202 projects, continuing care retirement communities (CCRCs), ILFs and certain assisted living providers, struggle to find a balance between implementing meaningful measures to protect residents and staff in their unique independent and assisted living settings while complying with contractual obligations and applicable laws, including residents' civil rights under the Fair Housing Act. Until this interim guidance was issued, a common approach among CCRCs and ILFs was to incorporate the guidance already made available to the long term care providers that offer medical services to ensure the highest level of safety. The interim guidance, in fact, specifically notes that CCRCs that include a long term care facility can consider adopting those more stringent recommendations. While that approach may work well for some providers, this new interim guidance takes into account that residents in retirement communities generally care for themselves, alone or through the assistance of others, including friends, family, sitters, private duty aides, and other third-party caregivers. Regardless of the approach, the CDC encourages providers and stakeholders to work together with residents, staff members, volunteers, and the local health departments in slowing the spread of diseases and helping ensure residents are safe.

The interim guidance offers owners, administrators, and operators numerous recommendations on how to help slow the spread of the virus. In addition to more generally applicable guidance (such as cleaning and disinfecting common areas, providing information about the virus, screening, etc.), the CDC offers the following specific guidance for this setting:

• Cancelling all public or non-essential group activities and events. For activities that cannot be cancelled, providers should implement social distancing measures such as staggering meals, activities, arrival and departure times, limiting the number of attendees to fewer than ten people and setting up rooms so that chairs and tables are at least six feet apart. Recognizing the potentially devastating impact isolation can have on residents, the CDC provides guidance on managing stress and anxiety during this outbreak.
• Limiting the number of non-essential visitors. Until now HUD has not issued guidance to housing providers regarding visitors, and therefore, this CDC guidance has been helpful for providers looking for official authorization before implementing such policies. The recommendations suggest considering a maximum of one visitor per resident per day, and restricting visitors who have symptoms of COVID-19 or who recently travelled to high risk areas.
• Helping residents establish a "buddy" system to ensure they stay connected. The CDC recommends such a program so that residents with unique medical needs and access and functional needs have a plan in place in the event that their primary caregiver becomes ill. Such volunteer 'buddies' can be trained on following personal protective measures. The interim guidance also acknowledges the role electronic communication and other technologies can play in helping ensure the safety and well-being of residents.
• Encouraging personal protective measures. This measure is specifically applicable to third-party private duty aides and others who provide care to multiple residents in the residents' respective homes or otherwise, such as housekeepers, sitters, hairdressers and barbers. The interim guidance recommends limiting the number of people with whom they interact and maintaining an appropriate distance when interacting. For example, more and more providers are now suspending all beauty salon services at these communities.

Additionally, the interim guidance provides instruction to residents, visitors, volunteers, and workers to reduce the spread of illness, such as the following:

• Residents should follow instructions regarding personal hygiene, keep their homes clean and disinfected, consult with their physicians regarding keeping an extra supply of regular prescriptions, and ensure continuity of care through electronic means such as telemedicine.
• Volunteers, visitors, and workers should, among other things, avoid entering private residences, or the facility in its entirety, unless their presence is essential to preserving the health of residents, including mental health and well-being.

Finally, the interim guidance provides more detailed instruction on what to do when a case of COVID-19 has been confirmed in the retirement facility or ILF. In such a case, the CDC recommends that:

• Owners, administrators, and operators request the person self-isolate and contact the local health officials, as well as notify the local health department about any clusters of residents or workers with respiratory illness (e.g. three or more persons with onset of respiratory symptoms within 72 hours).
• Communicate with residents, workers, volunteers, and visitors regarding possible COVID-19 exposure through signage in common areas and entrances and exits as well as by letters to all residents. Such communications must comply with confidentiality requirements under the ADA as well as HIPAA, as applicable, and counter potential stigma and discrimination.
• Request the resident self-monitor for 14 days by taking their own temperature twice daily, and taking preventative measures if they feel feverish, have a temperature above 100.4 degrees Fahrenheit, or experience difficulty breathing or a cough, such as staying home, limiting contact with others, reporting their illness to the owners, administrators, or operators, seeking advice from a health care professional, and following CDC guidance on when to discontinue isolation.

The interim guidance provides helpful recommendations that CCRCs and ILFs can implement immediately; however, in certain cases, if a resident who has the virus does not agree to follow these recommendations (or the family or responsible party or parties refuse to comply), then the provider will need to consider what legal options exist in order to protect its community, including other residents and staff. Central to such analysis will be the admissions agreement or residency agreement, the resident handbook, and potentially applicable landlord/tenant laws. Balancing the rights of any resident who may have been exposed to COVID-19 with the rights of other residents in the community will likely be challenging because of the novelty of the issue and the immediate need for action to prevent spread.