Gurwin Jewish Nursing & Rehabilitation Center ‘s Pandemic Emergency Plan (PEP) is a compilation of “all-hazards” general principles, policies, and procedures for administration and staff to follow in effectively responding to an emergency incident or unusual situation either within the facility or within the community.
This PEP was established to protect the health and the safety of Gurwin’s residents, staff and visitors; alleviate damage and hardship; and reduce future vulnerability to hazards that may disrupt normal activities within the facility. This PEP is a living document that will be reviewed annually, at a minimum by our Chief Quality Officer. Gurwin’s PEP takes into account potential hazards from the local area and the impact they could have on the nursing home. We rely on past experiences and lessons learned in describing risks and include unique physical plant details improving or aggravating the facility’s vulnerability. A Hazard Vulnerability Analysis (HVA) tool is completed as a facility-based, and community-based risk assessment, utilizing an all-hazards approach to develop a common understanding about the hazard risks that Gurwin’s faces. The HVA helps to prioritize issues for the PEP to address, by creating an orderly process for identifying the facility’s highest vulnerabilities.
The Hazard Annex P: Infectious Disease/Pandemic Plan has been updated to include guidance and formatted to comply with the new requirements of Chapter 114 of the Laws of 2020 for the development of a Pandemic Emergency Plan (PEP). The Pandemic Emergency Plan is designed to easily identify the information needed to effectively plan for, respond to, and recover from, natural and manmade disasters.
1.P r ovide staff education on infectious diseases (e.g. reporting requirements (see Annex K of the CEMP toolkit); exposure risks; symptoms prevention; and infection control; correct use of personal protective equipment; regulations, including 10 NYCRR 415.3(i)(3)(iii), 415.19, and 415.26(i) 42 CFR 483.15(e) and 42 CFR § 483.80); and Federal and State guidance/requirements.
A plan is in place to provide education and training to ensure all personnel understand the implications, and basic prevention and control measures, including recognizing exposure risks and utilizing personal protective equipment (PPE) correctly, reporting requirements and regulations.
The Education Coordinator and Infection Control Preventionist (ICP) have been designated with the responsibility for coordinating education and training on the Infectious Disease/Pandemic Emergency Plan.
Education is provided on Infection Prevention and Management upon hire of new staff, as well as ongoing education on an annual basis and as needed.
The ICP/Education Coordinator will conduct annual competency-based education on hand hygiene and donning/doffing PPE for all staff.
Current and potential opportunities for long-distance (e.g. web-based) and professional programs have been identified.
Language and reading-level appropriate materials will be identified to supplement and support education and training programs and a plan is in place for obtaining these materials.
Education and training includes information on infection control measures to prevent the spread of Infectious Disease/Pandemic Illnesses, correct use of PPE, exposure risks, screening and detection, and reporting requirements and regulations.
The facility has a plan for expediting the credentialing and training staff brought in from other locations to provide resident care when facility reaches a staffing crisis.
Informational materials (brochures, fliers, posters) on pandemic illness and relevant policies (suspension of visitation, communication) will be available for residents and their families. A plan is in place on how to disseminate these materials in advance of the actual pandemic. (Policy on communication via website)
Refer to Communication/Notification of Infectious Disease/Pandemic Illness Cases to the DOH, CDC, Residents, their Family Members or Representatives
Refer to Infection Prevention Lesson Plan
Refer to Infection Prevention Staff Training Policy
Refer to Criteria for Credentialing Staff during a Pandemic Emergency/Infectious Disease
2.D evelop/Review/Revise and enforce existing infection prevention, control, and reporting policies.
The Infection Control Policy and Procedure manual has been reviewed and updated by the Chief Nursing Officer, Infection Control Preventionist, Interim Medical Director, Chief Quality Officer and Administrator.
The facility will continue to review/revise as well as enforce existing infection prevention and control and reporting policies.
The facility will update the Infection Control Manual, which is available in a digital and print format for all staff, annually or as required during a pandemic event.
An infection control policy that requires all direct care staff to use Standard and Transmission-based Precautions when in close contact with symptomatic residents is in place.
3.C onduct routine/ongoing, infectious disease surveillance that is adequate to identify background rates of infectious diseases and detect significant increases above those rates. This will allow for immediate identification when rates increase above these usual baseline levels.
ICP has been assigned responsibility for monitoring public health advisories (federal and state) and updating Administration and members of the pandemic planning committee when a pandemic illness has been reported in the United States and its nearing geographic area.
The following resources are utilized for infectious disease threat information and planning:
The Centers for Disease Control and Prevention Health Alert Network (
https://emergency.cdc.gov/han/updates.asp) State and local health departments
Centers for Medicare and Medicaid Services (CMS)
Evaluation and diagnosis of residents and/or staff with symptoms will follow current Centers for Disease Control and Prevention (CDC) guidelines for evaluation of symptoms and laboratory diagnostic procedures. The guidelines will be used to enhance infection surveillance.
Enhanced surveillance of residents and staff will be considered on a case-by-case basis in collaboration with the local public health department. Enhanced surveillance will be based upon the clinical presentation of symptoms, risk factors for exposure, and current CDC recommendations.
All staff will receive annual education on reporting any change in resident condition to supervisory staff.
A protocol has been developed for infectious disease surveillance and documentation to identify and detect increases above the established baseline infection rate. This data will be documented and reported at the Quality Assurance Performance Improvement (QAPI) Committee meetings to identify trends and any area for improvement.
As needed, the Chief Quality Officer will establish QAPI Projects to identify root cause(s) of infections and update the facility action plans, as appropriate. This will be reported to the QAPI Committee.
The facility will utilize morning report to identify any trends and patterns of infections and/or symptoms.
The ICP will monitor and internally review transmission of pandemic illness among staff and residents and report regularly to the QAPI Committee. Information from this monitoring system is used to implement prevention interventions (cohorting, isolation) and will be necessary to assess pandemic illness.
Refer to Policy on Acute Change in Condition
Refer to Policy on Surveillance and Identification of Infection
Refer to Policy on Surveillance During Pandemic Emergency
4.D evelop/Review/Revise plan for staff testing/laboratory services.
The facility will conduct staff testing, as indicated, in accordance to NYS Department of Health (DOH) and CDC recommendations for infectious illness/pandemic.
The facility will have prearranged arrangements with laboratory services to accommodate any testing of residents and staff, including contract employees.
The Administrator will ensure ongoing surveillance to ensure compliance with staff and resident testing and results.
Refer to P/P Staff Testing During an Infectious Disease/Pandemic Emergency
5.R eview and assure that there is adequate facility staff access to communicable disease reporting tools and other outbreak-specific reporting requirements on the Health Commerce System.
The facility has a directive in place, which includes adequate staff to access reporting tools on communicable disease via Health Commerce System, National Healthcare Safety Network (NHSN), National Occupational Research Agenda (NORA) and Health Emergency Response Data System (HERDS) survey reports.
The facility has developed a policy based on regulations for reporting to NYSDOH.
Confirmed and suspected cases of reportable infectious diseases are reported to the local health department and CDC as appropriate
The ICP/Designee will enter any data in the NHSN as per CMS/CDC guidance.
Refer to P/P on Reporting of Suspected or Confirmed Communicable Diseases
6.D evelop/Review/Revise internal policies and procedures, to stock up on medications, environmental cleaning agents, and PPE as necessary. (Include facility’s Chief Medical Officer, Chief Nursing Officer, Infection Control Preventionist, Safety Officer, Chief Human Resources Officer, local and state public health authorities, and others as appropriate in the process.)
The following departments have input in selecting, acquiring and reviewing the policies for stocking needed supplies: Chief Medical Officer, Chief Nursing Officer, Infection Control Preventionist, Safety Officer, Chief Housekeeping Officer, Director of Pharmacy, Chief Human Resources Officer, Chief Quality Officer and Purchasing Director, as well as local and state public health authorities.
The facility has developed a policy for optimizing PPE and will be cognizant of emerging pathogens and illnesses at the time of the pandemic and plan to handle worst-case scenarios without incurring shortages.
The facility has established par levels for PPE. The facility has identified a secure storage area for a minimum 60-day supply of PPE. Supplies to be maintained include:
Sanitizer and disinfectants in accordance with current EPA guidance
The facility has developed a policy on stocking up on medication in the event of pandemic
Refer to P/P Strategies to Optimize PPE during Contingency and Crisis Capacity during Infectious Illness/Pandemic Emergency
Refer to PPE Emergency Supply
Refer to Policy on Cleaning Products
Refer to Policy on Purchasing Supplies During Pandemic
Refer to Policy on Pharmacy Emergency Supply of Medication
7.D evelop/Review/Revise administrative controls (e.g., visitor policies, employee absentee plans, staff wellness/symptoms monitoring, human resource issues for employee leave).
The facility has developed a policy for visitation based upon knowledge of community occurrence of pandemic illness and regulatory guidance.
The facility has developed a liberal/non-punitive sick leave policy that addresses the needs of symptomatic personnel and facility staffing needs. The policy considers:
The handling of personnel who develop symptoms while at work;
When personnel may return to work after recovering from a pandemic illness;
Personnel who need to care for family members who become ill.
All sick calls will be monitored by Department Heads to identify any staff pattern or cluster of symptoms associated with an infectious agent/illness. Each Department Head will notify ICP/HR with issues.
A plan to educate staff to self-assess and report symptoms of pandemic illness before reporting to duty has been developed.
The facility developed a plan for health screening and thermal temperature checks to be done upon entrance to the facility for all employees, contract staff, vendors, and visitors during pandemic emergency
. Each department has developed a contingency staffing plan that identifies minimum staffing needs and prioritizes critical and non-essential services, based upon resident needs and essential facility operations. The plan includes collaboration with local and regional DOH and CMS to address widespread healthcare shortages during a crisis.
Refer to Visitation During Pandemic Policy
Refer to Entrance Screening of Employees, Visitors and Vendors during Infectious Disease /Pandemic Emergencies
Refer to Contingency Staffing Plan
Refer to Policy Reporting New-Onset of Staff with Respiratory Symptoms and Infectious Disease/Pandemic Illness During Pandemic Emergency
Refer to Pandemic Return to Work HR Policy
8.D evelop/Review/Revise environmental controls (e.g. areas for contaminated waste).
Storage areas for contaminated waste are clearly identified as per NYSDOH guidelines.
The Housekeeping Department will be trained in handling contaminated waste and will be given proper PPE to utilize when performing these tasks.
The facility will amend its policy on biohazardous waste as needed related to any new infectious agent and mode of transmission.
Refer to Policy on Medical Waste Handling
9.D evelop/Review/Revise vendor supply plan for re-supply of food, water, medications, other supplies, and sanitizing agents.
The facility has a 3-4 day emergency supply of food and water available. This is monitored on a quarterly basis to ensure it is intact and stored safely.
The facility has adequate supply of stock medications for 90 days.
The facility has access to a minimum of a 60-day supply of cleaning/sanitizing supplies.
The Department Head responsible for monitoring the emergency supplies will notify the Administrator of any specific needs or shortages.
10.D evelop/Review/Revise facility plan to ensure that residents are isolated/cohorted and or transferred based on their infection status in accordance with applicable NYSDOH and CDC guidance.
A plan has been developed for cohorting symptomatic residents or groups using one or more of the following strategies:
1. Confining symptomatic residents and their exposed roommates to their room;
2. Placing symptomatic residents together in one area of the facility;
3. Cohorting into groups in relation to lab test results; or,
4. Closing units where symptomatic residents reside (i.e., restricting all residents to an affected unit, regardless of symptoms).
The plan includes, where possible, dedicating staff to work on affected units, who will not work on other units.
The residents in the facility will be cohorted based upon their status in accordance with CDC and NYSDOH guidance. Staff will be educated on the specific requirements for each cohort group.
Cohorts may be divided into 3 groups: Unknown, Negative and Positive as it relates to the known infectious agent.
Residents will be transferred to the hospital during a pandemic emergency based on their infection status in accordance with applicable NYSDOH and CDC gui
Residents that require transfer to another health care setting will have their cohort (infection status) communicated to transporter and documented on transfer documents.
Refer to Policy on Cohorting
11.D evelop plans for cohorting, including using of a part of a unit, dedicated floor, wing in the facility or a group of rooms at the end of the unit, and discontinuing any sharing of a bathroom with residents outside the cohort.
The facility will dedicate a group of rooms at the end of a unit, wing, or unit. This dedicated area will be created using moveable ICRA panels. The designated cohort area will not share the bathroom with residents outside the area.
Signage will be on doors and entrances to clearly identify area and admittance requirements.
All attempts will be made to have dedicated staff assigned to each cohort group and to minimize the number of different caregivers entering the rooms.
Refer to Policy on Use of Starc ICRA Panels
12.D evelop/Review/Revise a plan to ensure social distancing measures can be put into place where indicated (describe facility’s process, e.g. which non-essential activities to eliminate, changes in dining/other physical space arrangements involving residents/staff, etc.)
The facility will review and revise the policy on communal dining programs to ensure social distancing is adhered to in accordance to NYSDOH guidelines and CDC recommendations during the pandemic emergency.
The facility will review and revise the policy on recreational activities during a pandemic to ensure social distancing is adhered to in accordance to NYSDOH guidelines and CDC recommendations. Recreational programing will be individualized for each resident.
Social distancing signage will be placed in employee locker rooms and dining areas.
Facility lounge areas will have furniture removed to allow for social distancing.
Signage on flooring will be placed noting social distancing (i.e. time clock, entrance to facility, employee dining areas).
Social distancing signage will be placed on units and in resident dining areas.
Staff will be educated on these services and updates as needed.
13.D evelop/Review/Revise a plan to recover/return to normal operations when, and 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 adhere to directives by the NYSDOH and CDC at the time of the pandemic event, e.g. regarding how, when, which activities /procedures /restrictions may be eliminated/restored and the timing of when those changes may be execut
The facility will maintain communication with local NYSDOH and CMS and follow their guidelines for returning to normal operations.
The facility will update the website when restrictions are eliminated and normal operations occur.
Resumption of services from non-essential employees (e.g. volunteers) will be made based upon CMS and NYSDOH recommendations.
Resumption of routine consultations will be made on a case-by-case basis based upon medical necessity and exposure risk.
Monitoring of residents and employees will continue as directed by NYSDOH.
Refer to Policy and Procedure: Consultants
Refer to Policy on Monitoring of Staff/Residents During the Recovery/Return to Normal Activities After Pandemic Emergency
14.I n accordance with Pandemic Emergency Plan (PEP) requirements, develop/review/revise a Pandemic Communication Plan that includes all required elements of the PEP.
The Chief Social Work and Public Relations Officers will ensure that there is an accurate list of each resident’s representative, and preference for type of communication.
The Public Relations team will update the facility website on the identification of any infectious disease outbreak or potential pandemic.
The facility will utilize phone calls, mailings, email, internet, and posted signage to alert visitors, family members, and employees about the status of the infectious disease in the facility/community.
Refer to Communication System for Informational Materials on Pandemic Illness and Relevant Policies to Families and Residents
15.I n accordance with PEP requirements, development/review/revise plans for protection of staff, residents and families against infection that includes all required elements of the PEP.
The facility has developed Plans for Protection which include:
Screening of staff, vendors, and contract employees
Screening of residents on admission
Visitor restrictions in accordance with NYSDOH and CDC
Proper use of PPE
Cohorting of staff and residents
Testing of residents/staff
Surveillance of residents
Implementation of social distancing
All appropriate departments will be involved in the development, review and revision of facility plan for protection of staff, residents, and families against infection.
Refer to Admission Screening Process
16.The facility will implement the following procedures to obtain and maintain current guidance, signage, advisories from the NYSDOH and CDC on disease-specific response actions e.g. including management of residents and staff suspected or confirmed to have disease.
The facility will obtain and maintain current guidance, signage advisories from NYSDOH and CDC on infectious illness/pandemic emergency.
Signage will be posted by the ICP in the facility which will include information on newly emergent infectious agents, symptoms and transmission.
The ICP will ensure appropriate signage is visible in the facility at key areas: entrances, lobby, time clocks, employee break rooms, units, etc.
Refer to CDC website for signage download
17. The facility will assure it meets all reporting requirements for suspected or confirmed communicable diseases as mandated under the New York State Sanitary Code (10NYCRR 2.10 Part 2), as well as by 10 NYCRR 415.19.
The facility will meet 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.
The ICP/Designee will be responsible to report communicable diseases on NHSN as directed by CMS.
The ICP/Designee will be responsible to report communicable diseases via the NORA reporting system on the HCS.
18. The facility will assure it meets all reporting requirements of the Health Commerce S ystem, e.g. HERDS survey reporting.
The facility assures it meets all reporting requirements of the Health Commerce System, e.g. HERDS survey reporting.
The ICP/Designee will be responsible to report communicable diseases via the NORA reporting system on the HCS.
19. The Infection Control Practitioner will clearly post signs for cough etiquette, hand washing, and other hygiene measures in high visibility areas. Consider providing hand sanitizer and face/nose masks, if practical.
The ICP will ensure signage includes awareness on cough etiquette, hand washing, and other hygiene areas in visible areas throughout the facility.
Alcohol-based, touchless hand sanitizer dispensers are located throughout the facility at the following locations: each nursing unit hallway, all entrances /exits, rehab gyms, outside dining areas, lobby areas, and at time clocks. Hand washing sinks are located in all the resident dining rooms, nursing stations, medication rooms, resident rooms, meeting areas, and gyms. Hand sanitizers are located in dining rooms, gyms, on medication carts and in all personal offices.
The facility promotes good hand hygiene through education and signage throughout the facility including rest rooms, and at the entrance.
The facility intranet has a hand hygiene video for all staff for review.
Hand hygiene competencies are completed by all departments and reported to the QAPI Committee.
The facility will ensure the bathrooms and other hand washing areas are well-stocked with hand soap and paper towels.
20.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.
The facility will limit exposures 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 polici
Facility will implement cohort policies for residents based upon their infection status.
Facility will monitor all residents to identify infection or symptoms of the infectious agent.
The facility will quarantine units and suspend admissions based upon guidance from NYSDOH and CDC.
Facility will follow guidance and restrictions from NYSDOH regarding visitation, communal dining, activities, and testing.
Facility will screen all persons entering building as directed by NYSDOH and CDC based upon infectious agent.
Clinical staff will use alternative measures to communicate with infectious residents to limit exposure such as telephones and videoconferencing as appropriate.
21.The facility will implement the following procedures to ensure that, as much as is possible, separate staffing is provided to care for each infection status cohort, including surge staffing strategies.
The facility will implement procedures to ensure that, as much as is possible, separate staffing is provided to care for each infection status cohort, including surge staffing strategies
22.The facility will conduct cleaning/decontamination in response to the infectious disease in accordance with any applicable NYSDOH, EPA and CDC guidance, as well as with facility policy for cleaning and disinfecting of isolation rooms.
The facility will conduct cleaning/decontamination in response to the infectious disease in accordance with any applicable NYSDOH, EPA and CDC gui
Housekeeping services will include increased cleaning of high-touch areas throughout the facility.
Refer to Daily Room Cleaning During Infectious Disease/Pandemic Emergency
Refer to P/P Terminal Room Cleaning
Refer to Pandemic Equipment Cleaning
Refer to Vinyl Cubicle Curtain Cleaning
Refer to Policy on Cleaning High-Touch Areas
23.The facility will implement the following 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:
The facility will implement the 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 informati
All residents and families will receive ongoing information on the infectious agent, transmission, prevention measures, and any changes in the facility policies. This will be posted by Public Relations on the website, in e-newsletters, and using the facility’s closed circuit TV channel.
The facility’s website will include a FAQ section related to the infectious disease.
The Public Relations Department will be responsible to review, delegate and/or respond to all correspondence on the facility’s website.
Informational brochures will be made available on infection control measures at the entrance.
24.The facility will contact all staff, vendors and other relevant stakeholders on the facility’s policies and procedures related to minimizing exposure risks to residents. Provide information regarding facility-maintained list of external stakeholders to be contacted and mechanisms for sharing this information.
The facility will contact all staff, vendors and other relevant stakeholders on the facility’s policies and procedures related to minimizing exposure risks to both residents and staff.
The facility will follow visitor restrictions as per NYSDOH guidance. Any restriction will be posted on website and at the entrance to the facility.
Vendors will be required to drop off deliveries at designated areas to avoid entrance into the facility.
The facility will post signage at the entrance noting visitor restrictions and requirements for entrance to the facility.
PPE will be worn by visitors during any scheduled visitation permitted during the emergency. Visitors will also be provided with written directions on visitation requirements to minimize exposure, the importance of frequent hand hygiene, and donning/doffing of PPE.
Medical consultants that service the residents will be notified and arrangements will be made for telehealth or postponing evaluation unless medically necessary.
25.S ubject to any superseding New York State Executive Orders and/or NYSDOH guidance that may otherwise temporarily prohibit visitors, the facility will advise visitors to limit visits to reduce exposure risk to residents and staff. If necessary, and in accordance with applicable New York State Executive Orders and/or NYSDOH guidance, the facility will implement the following procedures to close the facility to new admissions, limit visitors when there are confirmed cases in the community and/or to screen all permitted visitors for signs of infection:
The facility will follow all applicable NYS Executive Orders and/or NYSDOH guidance in pandemic emergency on visitation restrictions.
The facility will limit and or restrict visitors as per the guidelines from the NYSDOH.
Any restriction or change to the facility visitation policy will be posted on website and communicated to all residents and designated representative.
The facility will quarantine units and suspend admissions based upon guidance from the NYSDOH and CDC.
The facility developed a policy and procedure for health screening and thermal temperature checks to be done upon entrance to the facility for all employees, contract staff, vendors, and visitors during pandemic emergency
Refer to Policy on Admission Screening Process
Refer to Policy on Compassionate Care/End-Of-Life Visitation- Infectious Disease/Pandemic Emergency
26.E nsure staff are using PPE properly (appropriate fit, don/doff, appropriate choice of PPE per procedures).
The facility has a Respiratory Protection Program.
Signage will be posted on all doors of resident rooms indicating the PPE required prior to entrance into the room, as applicable.
Signage will be posted on the entrance to any unit on quarantine.
Staff will be re-educated on PPE use and have a competency evaluation for donning and doffing of PPE.
PPE is located on units to ensure access at all times.
The facility has a designated person to ensure adequate and available PPE is accessible on all shifts.
Surveillance rounds are made by ICP, Nursing Care Coordinator, and Administrative staff to ensure compliance with proper use of PPE. Findings are reported to QAPI Committee.
Refer to Policy on Respiratory Protection Program
See Infection Control Surveillance Audit Tool
Refer to Policy on PPE
27.I n accordance with PEP requirements, t he facility will follow the following procedures to post a copy of the facility’s PEP, in a form acceptable to the commissioner, on the facility’s public website, and make it available immediately upon request:
A copy of the facility’s PEP will be posted in a form acceptable to the commissioner on the facility’s website and made available immediately upon request by 9/15/20.
The PEP will be available for review on the shared drive of the facility’s policies.
28. I n accordance with PEP requirements, t he facility will utilize the following methods to update authorized family members and guardians of infected residents (i.e., those infected with a pandemic-related infection) at least once per day and upon a change in a resident’s condition:
The facility will communicate with residents and representatives as per their preference.
During a pandemic emergency, representatives of residents infected with an infectious agent will be notified daily and with significant change by nursing/medical staff as to their status.
All resident representatives will be notified weekly on the status of the pandemic at the facility, which includes the number of pandemic infections and deaths, including residents that expire for reasons other than such infection (e.g. infected with infectious agent bur who expire for reasons other than infectious agent).
Updates will be given to residents and representatives within 24 hours indicating any newly confirmed cases and/or deaths related to the infectious agent.
All residents will be provided with daily access to communicate with their family member and guardians. The type of communication will be based upon the resident’s preference (i.e. video conferencing, telephone calls, and/ or email.)
29. I n accordance with PEP requirements , the facility will implement the following procedures/methods to ensure that all residents and authorized families and guardians are updated at least once a week on the number of pandemic-related infections and deaths at the facility, including residents with a pandemic-related infection who pass away for reasons other than such infection:
30. I n accordance with PEP requirements , the facility will implement the following mechanisms to provide all residents with no-cost, daily access to remote video conference or equivalent communication methods with family members and guardians:
The facility will provide residents, at no cost, daily access to remote videoconferencing or equivalent communication method with family member and guardians.
The Director of Therapeutic Recreation will be responsible to arrange time for all videoconferencing.
31. I n accordance with PEP requirements, t he facility will implement the following process/procedures to assure hospitalized residents will be admitted or readmitted to such residential health care facility or alternate care site after treatment, in accordance with all applicable laws and regulations, including but not limited to 10 NYCRR 415.3(i)(3)(iii), 415.19, and 415.26(i); and 42 CFR 483.15(e):
The facility will implement procedures to assure hospitalized residents will be admitted or readmitted to the health care facility or alternate care site after treatment, in accordance with all applicable laws and regulations, including but not limited to 10 NYCRR 415.3(i)(3)(iii),
The admission nurse in conjunction with nursing leadership will review hospital records to identify the resident needs, exposure risk to infectious agent, and the facility’s ability to provide care including cohorting and treatment needs.
Refer to Policy and Procedure for Bed Hold During Pandemic
32.I n accordance with PEP requirements, t he facility will implement the following process to preserve a resident’s place in a residential health care facility if such resident is hospitalized, 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):
The facility will implement processes to preserve a resident’s place in a residential health care facility if such resident is hospitalized, 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).
33. I n accordance with PEP requirements, t he facility will implement the following planned procedures to maintain or contract to have at least a two-month (60-day) supply of PPE (including consideration of space for storage) or 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. As a minimum, all types of PPE found to be necessary in the COVID pandemic should be included in the 60-day stockpile. This includes, but is not limited to:
1. N95 respirators
2. Face shields
3. Eye protection
4. Gowns/isolation gowns
7. Sanitizer and disinfectants (meeting EPA Guidance current at the time of the pandemic)
The facility has implemented procedures to maintain at least a two-month (60-day) supply of PPE (including consideration of space for storage) or 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.
This includes, but not limited to:
1. N95 respirators
2. Face shields
3. Eye protection
4. Gowns/isolation gowns
7. Sanitizer and disinfectants (meeting EPA Guidance current at the time of the pandemic)
The facility will calculate daily usage/burn rate to ensure adequate supply of PPE.
34. The facility will maintain review of, 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.
The facility will maintain review of, 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.
The facility will document recovery events on tracking log.
35. The facility will communicate any relevant activities regarding Recovery/Return to Normal Operations, with staff, families/guardians and other relevant stakeholders.
The facility will communicate any relevant activities regarding Recovery/Return to Normal Operations, with staff, families/guardians and other relevant stakeholders.
During the recovery phase, all residents, staff, and contracted employees will be monitored and tested to identify any developing symptoms related to infectious agent in accordance with NYSDOH and CDC guidance.
We won’t ever forget their kindness.
“From the moment of our arrival, your staff was kind, efficient and went out of their way to care for my father, as well as my family. The nurses; aides; physical, speech and occupational therapists; and social worker that followed my father were so patient, kind and tolerant. Although I would never want to have to see anyone else in my family go through such an illness again, it is good to know there are facilities as wonderful as yours if we should ever need them. Please extend our love and thanks to this incredible group of people. They made his stay as wonderful as possible and helped my family through a very difficult time. We won’t ever forget their kindness.”
-Anthony & Theresa D.