SEPTEMBER 15, 2020


Preparedness Planning

Staff Education on Infectious Diseases 

  • Staff Education on infectious diseases information, prevention and management, will be performed via multiple venues. Venues include on unit huddles, town halls, multimedia, and new staff orientations.
  • Education will be performed by Infection Control Team (DON, ADON, Infection Control Coordinator, Medical Director, Department Heads, Nurse Managers), upon hiring of new staff, annually and as needed.
  • Education includes, as part of facility protocol, daily reporting and weekly surveillance to Infection Control Team, and how it interacts with regulations around resident abuse (10NYCRR 415.3(i)3(iii), 415.19, 415.26(i), 42 CFR 483.15(e), 42 CFR 483.80).


Develop/Review/Revise and Enforce Existing Infection Prevention Control, and Reporting Policies 

  • The ICP, Medical Director and DON will continue to review/revise and enforce existing infection prevention control and reporting policies. The Facility will update the Infection Control Manual, which is available in a digital and print form for all staff, annually or as may be required during an event. From time to time, the Infection Control Team will consult with local Epidemiologist. CDC and DOH to ensure that any new regulations and/or areas of concern as related to Infection Prevention and Control are incorporated into the Facility’s Infection Control Prevention Plans.
  • Infection Control Practices enforced via rounding by Infection Control Preventionist (ICP) and Nurse Managers/supervisors.




Conduct Routine/Ongoing, Infectious Disease Surveillance

  • ICP, Medical Director, DON meets Bi weekly to review all infections and antibiotic usage and follow up with Nurse Managers. Infection Control Team generates monthly reports and presents quarterly to QAPI.
  • As needed the QAPI team will identify root cause(s) of infections and update the facility action plans, as appropriate, based on what is reported by the Infection Control Team.
  • DON and ICP reviews infections and antibiotic use with the managers weekly and as needed.
  • Unit staff will identify daily and track any infectious diseases and antibiotic use and submits weekly to ICP.


Develop/Review/Revise Plan for Staff Testing/Laboratory Services 

  • The Facility will conduct staff testing, if indicated, in accordance with NYS regulations and Epidemiology recommendations for a given infectious agent.
  • The facility shall have prearranged agreements with laboratory services to accommodate any testing of residents and staff including consultants and agency staff. These arrangements shall be reviewed by administration not less than annually and are subject to renewal, replacement or additions as deemed necessary. All contacts for labs will be updated and maintained in the communication section of the Emergency Preparedness Manual.
  • ICP and Medical Director will check daily for staff and resident testing results and take action in accordance with State and federal guidance.
  • ICP will track Invasive lines, Foleys ,cultures ,antibiotics and residents on precautions and communicates with staff any findings


Staff Access to Communicable Disease Reporting Tools 

  • The following Staff Members have access to the NORA and HERDS surveys on the HCS:   Administrator, Infection Control Preventionist, Director of Nursing, and Assistant Director of Nursing.  Should a change in staffing occur, the replacement staff member will be provided with log in access and Training for the NORA and HERDS Survey
  • The IP/designee will enter any data in NHSN as per CMS/CDC guidance


Develop/Review/Revise Internal Policies and Procedures for Stocking Needed Supplies 

  • In the event of an emergency; the Medical Director, Director of Nursing, Infection Control Practitioner, Safety Officer, Environmental Director and other appropriate personnel will convene to review the Policies for supplies needed and stocking methods.
  • Residents have a 4 week supply of medications on hand. We have stock of essential meds available in our Nexsys machine and emergency drugs in crash carts on every unit. In the event of a Pandemic in which new medications will be utilized, there is space to add stock meds in the Nexsys as needed.
  • In the event of an emergency and pharmacy is unable to deliver, our contracted pharmacy (Pharmscript) has contracts with all 24-hour pharmacy chains. Pharmscript will reach out to a local pharmacy to ensure availability and timely delivery of necessary medications.
  • Environmental Director has established par Levels for Environmental Protection Agency (EPA) approved environmental cleaning agents based on pandemic usage.
  • The facility has established par Levels for PPE.


Develop/Review/Revise Administrative Controls with regards to Visitation and Staff Wellness 

  • The facility administration will closely follow all notification/updates/guidance regarding a potential pandemic/outbreak.
  • Following the knowledge/notification of a potential pandemic/outbreak, the infection control and leadership committees will review established administrative controls for visitation, building access, screening of all employees, vendors onsite, vendor/delivery access and any other controls needed based on the type/level/severity of the infection.


Develop/Review/Revise Environmental Controls related to Contaminated Waste 

  • Areas for contaminated waste are clearly identified as per NYSDOH guidelines
  • The facility environmental coordinator shall follow all Department of Environmental Conservation (DEC) and DOH rules for the handling of contaminated waste. The onsite storage of waste shall be labeled and in accordance with all regulations. The handling policies are available in the Environmental Services Manual and Infection Control Manual. Any staff involved in handling of contaminated products shall be trained in procedures prior to performing tasks and shall be given proper PPE.
  • The facility will amend the Policy and Procedure on Biohazardous wastes as needed related to any new infective agents.


Develop/Review/Revise Vendor Supply Plan for food, water, and medication 

  • The facility currently has a 3-4 days supply of food and water available.  This is monitored on a quarterly basis to ensure that it is intact and safely stored.  Contracted with a vendor for emergency delivery of kitchen supplies and food if needed in an emergency.
  • The facility has adequate supply of stock medications for 4 weeks.
  • The facility has access to a minimum of 2 weeks supply of needed cleaning/sanitizing agents in accordance with storage and NFPA/Local guidance. The supply will be checked each quarter and weekly as needed during a Pandemic. A log will be kept by the Director of Environmental Services and report to Administrator any specific needs and shortages.


Develop Plans to Ensure Residents are Cohorted based on their Infectious Status 

  • Residents are isolated/cohorted based on their infection status in accordance with applicable NYSDOH and Centers for Disease Control guidance.
  • Administrator, Medical Director, ICP, and DON maintains communication with Local Epidemiologist, NYS DOH, and CDC to ensure that all new guidelines and updates are being adhered to with respect to Infection Prevention.
  • Positives are cohorted in a designated area until cleared to transfer back to their unit.
  • The resident will have a comprehensive care plan developed indicating their Cohort Group and specific interventions needed.


Develop a Plan for Cohorting residents using a part of a unit, dedicated floor or wing, or group of rooms 

  • The Facility will dedicate a wing or group of rooms at the end of a unit in order to Cohort residents. This area will be clearly demarcated as isolation area.
  • Appropriate transmission-based precautions will be adhered to for each of the Cohort Groups as stipulated by NYS DOH
  • Staff will be educated on the specific requirements for each Cohort Group.
  • Residents that require transfer to another Health Care Provider will have their Cohort status communicated to provider and transporter and clearly documented on the transfer paper work.
  • All attempts will be made to have dedicated caregivers assigned to each Cohort group and to minimize the number of different caregivers assigned.

Develop/Review/Revise a Plan to Ensure Social Distancing Measures 

  • The facility will review/ revise the Policy on Communal Dining Guidelines and Recreational Activities during a Pandemic to ensure that Social Distancing is adhered to in accordance with State and CDC guidance.
  • The facility will review/revise the Policy on Recreational Activities during a Pandemic to ensure that Social Distancing is adhered to in accordance with State and CDC guidelines. Recreation Activities will be individualized for each resident.
  • The facility will ensure staff break rooms and locker rooms allow for social distancing of staff
  • All staff will be re-educated on these updates as needed


Develop/Review/Revise a Plan to Recover/Return to Normal Operations 

  • The facility will adhere to directives as specified by, State and CDC guidance at the time of each specific infectious disease or pandemic event e.g., regarding how, when, which activities/procedures/restrictions may be eliminated, restored and the timing of when those changes may be executed.
  • The facility will maintain communication with the local NYS DOH and CMS and follow guidelines for returning to normal operations. The decision for outside consultants will be made on a case by case basis taking into account medical necessity and infection levels in the community. During the recovery period residents and staff will continue to be monitored daily in order to identify any symptoms that could be related to the infectious agent.


Develop/Review/Revise a Pandemic Communication Plan

  • Social Workers will review all contact information on admission and review all resident contacts quarterly. Will review who the primary contact is, all contact info (phone #, mailing address, e-mail address) is up to date and preference for type of communication is noted. Will review quarterly with all alert patients their preference with what information is shared to ensure HIPAA compliance. Director of Social Work and HIM will review to ensure all information is complete.
  • HIM will generate a running list of all residents and contact information, quarterly, to ensure the list is ready to be used in the event of an emergency. The list to be updated in the shared “emergency“ drive.
  • Communication of a pandemic includes utilizing established Staff Contact List to notify all staff members in all departments. Staff contact list to be updated quarterly by HR and shared in the shared “emergency” drive. Contact information to include cell phone numbers, e-mail and mailing addresses.
  • The Facility will update website on the identification of any infectious disease outbreak of potential pandemic.


Develop/Review/Revise Plans for Protection of Staff, Residents, and Families Against Infection

  • Education of staff, residents, and representatives
  • Screening and serial testing of residents and staff
  • Social distancing
  • Visitor Restriction as indicated and in accordance with NYSDOH and CDC
  • Proper use of PPE
  • Cohorting of Residents and Staff

Response for All Infectious Disease Agents

Guidance, Signage, Advisories 

  • The facility will obtain and maintain current guidance, signage advisories from the NYSDOH and the U.S. Centers for Disease Control and Prevention (CDC) on disease-specific response actions.
  • The Infection Control Practitioner will be responsible to ensure that there are clearly posted signs, easily visible in designated areas for cough etiquette, hand washing, and other hygiene measures for any newly infectious agent.


Reporting Requirements 

  • The facility will assure it meets all reporting requirements for suspected or confirmed communicable diseases as mandated under the New York State Sanitary Code (10 NYCRR 2.10 Part 2), as well as by 10 NYCRR 415.19 (see Annex K of the CEMP toolkit for reporting requirements).
  • The DON/Infection Preventionist will be responsible to report communicable diseases via the NORA reporting system on the HCS and the NHSN as directed by CMS


Reporting Requirements 

  • The following Staff Members have access to the NORA and HERDS surveys on the HCS:   Administrator, Infection Control Preventionist, Director of Nursing, and Assistant Director of Nursing.  Should a change in staffing occur, the replacement staff member will be provided with log in access and Training for the NORA and HERDS Survey



  • The Infection Control Practitioner will be responsible to ensure that there are clearly posted signs, easily visible in designated areas for cough etiquette, hand washing, and other hygiene measures for any newly infectious agent.
  • The facility has hand sanitizer throughout the units and in high traffic areas. Face masks are given upon entry into the building and additional masks on the units.Limit Exposure 
  • The facility will implement the following procedures to limit exposure between infected and non-infected persons and consider segregation of ill persons, in accordance with any applicable NYSDOH and CDC guidance, as well as with facility infection control and prevention program policies.
  • Facility will Cohort residents according to their infection status


  • Facility will monitor all residents to identify symptoms associated with infectious agent.
  • Units will be quarantined in accordance with NYSDOH and CDC guidance and every effort will be made to cohort staff.
  • Facility will follow all guidance from NYSDOH regarding visitation, communal dining, and activities and update policy and procedure and educate all staff.
  • Facility will centralize and limit entryways to ensure all persons entering the building are screened and authorized.
  • Hand sanitizer will be available on entrance to facility, exit from elevators, and according to NYSDOH and CDC guidance
  • Daily Housekeeping staff will ensure adequate hand sanitizer and refill as needed.


Separate Staffing 

  • All attempts will be made to have dedicated caregivers assigned to each cohort group and to minimize the number of different care givers assigned, including surge staffing


Conduct Cleaning/Decontamination 

The facility will conduct cleaning/decontamination in response to the infectious disease utilizing cleaning and disinfection product/agent specific to infectious disease/organism in accordance with any applicable NYSDOH, EPA, and CDC guidance.


Educate Residents, Relatives, and Friends About the Disease and the Facility’s Response 

  • The facility will implement procedures to provide residents, relatives, and friends with education about the disease and the facility’s response strategy at a level appropriate to their interests and need for information.
  • All residents will receive updated information on the infective agent, mode of transmission, requirements to minimize transmission, and all changes that will affect their daily routines. Information from the CDC (VIS flyers) are placed at the entrance and on the units in both English and Spanish.
  • Communication will be via letters, e-mail updates, website and hotline updates for the residents and family.


Policy and Procedures for Minimizing Exposure Risk 

  • The facility will contact all staff including Agencies, vendors, other relevant stakeholders on the facility’s policies and procedures related to minimizing exposure risks to residents and staff. They will be encouraged to check in on the facility website for ongoing updates.
  • Consultants that service the residents in the facility will be notified and arrangements made for telehealth, remote chart review, or evaluating medically necessary services until the recovery phase according to State and CDC guidelines.
  • List of vendors and external stakeholders will be maintained and updated bi-annually by HR.


Advise Visitors, Vendors, Staff, and other stakeholders on facility policies to minimize exposure risks to residents

  • Subject to any superseding New York State Executive Orders and/or NYSDOH guidance that may otherwise temporarily prohibit visitors, the facility administration and infection control team will convene to review the data around the current spread of the infection and will make decisions on visitation and new admissions accordingly and a screening process for anyone entering the building.
  • Emergency staff including EMS will be informed of required PPE to enter facility
  • Vendors will be directed to drop off needed supplies and deliveries in a designated area to avoid entering the building.
  • The facility will implement closing the facility to new admissions in accordance with any NYSDOH directives relating to disease transmission


Additional Response for All Infectious Disease Agents

Ensure Staff Are Using PPE Properly 

  • The facility has an implemented Respiratory Protection Plan
  • Appropriate signage shall be posted at all entry points, and on each residents’, door indicating the type of transmission-based precautions that are needed.
  • Staff members will receive re-education and have competency done on the donning and doffing of PPE, annually and as needed.
  • Infection Control rounds will be made by the DON, IP, Nurse Managers and designee to monitor for compliance with proper use of PPE
  • The facility has a designated person to ensure adequate and available PPE is accessible on all shifts and staff are educated to report any PPE issues to their immediate Supervisor
  • ICP will fit test and keep documented fitting of all staff members annually.


Post a Copy of the Facility’s PEP 

  • The facility will post a copy of the facility’s PEP in a form acceptable to the commissioner on the facility’s public website and make available immediately upon request.
  • The PEP plan will be available for review by 9/15/20


The Facility Will Update Family Members and Guardians 

  • The facility will communicate with Residents, Representatives as per their preference i.e. Email, text messaging, calls/robocalls and document all communication preference in the CCP/medical record.
  • During a pandemic, representatives of residents that are infected will be notified and updated by Nursing staff as to the resident’s status and when there is a change in condition.
  • All residents will be provided with daily access to communicate with their representatives.  The type of communication will be as per the resident’s preference i.e. video conferencing/telephone calls, and/or email.


The Facility Will Update Families and Guardians Once a Week 

  • Representatives will be notified weekly on the status of the pandemic at the facility including the number of pandemic infections via the website, hotline, and their preferred method of communication.
  • The Hotline message/website will be updated weekly indicating any newly confirmed cases and/or deaths related to the infectious agent.
  • Residents will be notified weekly with regards to the number of cases and deaths in the facility unless they verbalize that they do not wish to be notified. This will be documented in the medical record/CCP


Implement Mechanisms for Videoconferencing 

  • The facility will provide residents with no cost, daily access to remote videoconference or equivalent communication methods with Representatives
  • Recreation, Social Work, Dietary split the residents on each unit for videoconference calls and document each encounter in the EMR.


Implement Process/Procedures for Hospitalized Residents 

  • The facility will allow for readmission of hospitalized residents during a pandemic in accordance with all applicable laws and regulations including but not limited to 10 NYCRR 415.3(i)(3)(iii), 415.19, and 415(i); and 42 CFR 483.15(e).
  • Prior to Admission/readmission the DON/ICP, or Medical Director will review hospital records to determine resident needs and facility’s ability to provide care including Cohorting and treatment needs.


Preserving a Resident’s Place 

  • The facility will reserve a hospitalized resident’s bed, in accordance with all applicable laws and regulations including but not limited to 18 NYCRR 505.9(d)(6) and 42 CFR 483.15(e), and the facility’s bed hold policy.


The Facility’s Plan to maintain at least a two-month supply of Personal Protective Equipment (PPE)

  • The facility has stockpiled a two-month (60 day) supply of PPE stored offsite with a plan a rotate the supply and will update based on any superseding requirements under New York State Executive Orders and/or NYSDOH regulations governing PPE supply requirements executed during a specific disease outbreak or pandemic.
  • In the event of a pandemic, if more supplies are needed and we are unable to obtain through all other venues, the facility has a contract with Medline (through a partnership with the DOH emergency stockpile) for distribution of supplies.
  • The facility’s stockpile includes, but is not limited to:
  • N95 respirators
  • Face shield
    • Eye protection
    • Isolation gowns
    • Gloves
    • Masks
    • Sanitizer and disinfectants (meeting EPA Guidance current at the time of the pandemic)
  • Facility will calculate daily usage/burn rate to ensure adequate PPE


Recovery for All Infectious Disease Events

Activities/Procedures/Restrictions to be Eliminated or Restored 

  • The facility will review and implement procedures provided in NYSDOH and CDC recovery guidance that is issued at the time of each specific infectious disease or pandemic event, regarding how, when, which activities/procedures/restrictions may be eliminated, restored and the timing of when those changes may be executed.


Recovery/Return to Normal Operations 

  • The facility will communicate any relevant activities regarding recovery/return to normal operations, with staff, families/guardians and other relevant stakeholders.
  • The facility will ensure that during the recovery phase all residents and staff will be monitored and tested to identify any developing symptoms related to the infectious agent in accordance with State and CDC guidance.
  • The facility will screen and test outside consultants that re-enter the facility, as per the NYS DOH guidelines during the recovery phase.