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Mission Statement:

This Facility will maintain an effective Pandemic Emergency Plan. The Facility will comply with all directives and guidelines by New York State Department of Health, Centers for Communicable Diseases and any other regulatory agencies. The Plan will include the Facility’s response and recovery from a natural and/or manmade disaster/hazard. All required and recommended elements, by the NYS DOH, have been addressed and incorporated into the Pandemic Emergency Plan. The Facility recognizes the risk associated with a pandemic and will utilize all available resources to meet the resident and staff needs. 



The circumstances of infectious disease emergencies, including ones that rise to the level of a pandemic, vary due to multiple factors, including type of biological agent, scale of exposure, mode of transmission and intentionality. Infectious disease emergencies can include outbreaks, epidemics and pandemics. A pandemic is an outbreak of an infectious disease that affects people or animals over an extensive geographical area. The impact of a novel virus, to which the general population would have little or no immunity, is not possible to predict as we have learned during the COVID-19 pandemic. We have also learned that the SNF population can be at increased risk of severe illness and mortality due to comorbidities and chronic illness. During a pandemic nursing homes may need to implement restricted visitation or manage a shortage of personal protective equipment and more difficult issues that may threaten the facility’s ability to remain operational.


Preparedness Tasks for all Infectious Disease Events

1. Staff Education on Infectious Diseases

  • The Facility Infection Preventionist (IP) in conjunction with Inservice Coordinator/Designee provides education on Infection Prevention and Management upon hire, annually and as needed for any identified infection prevention and control concerns /updates on an ongoing basis.

  • The IP in conjunction with the In-service Coordinator will in-service all staff on Infection Prevention policies and procedures as needed for event of an infectious outbreak including all CDC and State updates/guidance.

See Infection Control In-service Education Program in IP Manual

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

  • This facility will continue to review/revise and enforce existing infection prevention control and reporting policies.  As needed the facility will communicate with local Epidemiologist to ensure that any new regulations and/or areas of concern as related to Infection Prevention and Control are incorporated into the Facilities Infection Control Prevention Plans. The Emergency Preparedness plan and procedure will be reviewed and attested annually and as needed by the Administrator/designee

See Facilities Infection and Prevention Program in IP Manual


3. Conduct Routine/Ongoing, Infectious Disease Surveillance

  • At daily Morning Meeting, the IDT team will identify any issues regarding infection control and prevention.

  • Resident infections as well as the usage of antibiotics will be reviewed on a monthly basis to identify any trends.

  • Rates of infectious diseases and detection of significant increases above those rates will be identified and addressed.

  • Infection surveillance will be ongoing systematic, collection, analysis interpretation and dissemination of date to identify infections and to monitor adherence to recommended IPC practices

See Policy on Infection Control Surveillance in IP Manual

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

  • This Facility will conduct staff testing, if indicated, in accordance with NYS regulations and Epidemiology recommendations for a given infectious agent.

  • This facility shall have prearranged agreements with laboratory services to accommodate any testing of residents and staff including consultants and agency staff.

  • Administrator/ DNS/Designee will check daily for staff and resident testing results and take action in accordance with State and federal guidance.

Refer to Vendor List in Emergency Management Plan (EMP)

5. Staff Access to Communicable Disease Reporting Tools

  • Designated staff are assigned to access and report to Health Commerce System (HCS), National Operational Research Agenda (NORA) and National Healthcare Safety Network (NHSN). All roles are assigned and updated, as needed, for reporting to NYSDOH. 

See Annex K Section 1 Communicable Disease Reporting

See Guidelines for Infectious Outbreak Investigation

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

  • The Medical Director, Director of Nursing, Infection Control Practitioner, Safety Officer, and other appropriate personnel will review the Policies for stocking needed supplies.

  • The facility has contracted with Pharmacy Vendor to arrange for 4-6 weeks supply of resident medications to be delivered should there be a Pandemic Emergency.

  • This facility has established par Levels for Environmental Protection Agency (EPA) approved environmental cleaning agents based on pandemic usage.   

  • This facility has established par Levels for PPE. 

 See Vendor Contracts in EMP (Emergency Management Plan)

See Policy on Par Levels for resident medication, cleaning agents and PPE

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

  • All sick calls will be monitored by Department Director to identify any staff pattern or cluster of symptoms associated with infectious agent. Each Department Director will keep a line list of sick calls and report any issues to the IP/DNS/ Designee.

  • Staff members will be screened, on entrance to the facility, to include symptom check as per DOH and CDC guidance.

  • Visitors will be informed of any visitation restriction related to an Infection Pandemic. Any visitation restriction will be enforced/lifted as allowed by NYSDOH.

  • A contingency staffing plan is in place that identifies the minimum staffing needs and prioritizes critical and non-essential services, based on residents’ needs and essential facility operations. The staffing plan includes collaboration with local and regional DOH planning and CMS to address widespread healthcare staffing shortages during a crisis.

See Policy on Visitation Guidelines during Pandemic

See Policy on Staff Screening and Monitoring During a Pandemic

See Policy on Emergency Preparedness /Hazards Staffing Guidelines

8. 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. Any staff involved in handling of contaminated product shall be trained in procedures prior to performing tasks and shall be given proper PPE.

  • Facility will follow cleaning for standard terminal enhanced cleaning and Disinfection

See Policy on Control Methods in IP Manual

See Policy on Handling of Biohazardous Waste Materials

9. Develop/Review/Revise Vendor Supply Plan for food, water, sanitizing agents medication, and other supplies

  • Facility has vendor agreements in place for any/all supplies.

  • Facility maintains a minimum supply of 72 hours of food and water. This is monitored on a quarterly basis to ensure that it is intact and safely stored

  • Facility has adequate supply and access to medication from the Pharmacy and other related vendors.

  • Facility has access to supplies of cleaning/sanitizing agents.

  • Supply Logs will be kept by the Department Head who will be responsible for monitoring the supply and reporting to the Administrator/designee any shortages or needs.

Refer to Emergency Preparedness Manual & Policy on Subsistence Food and Water located int the EMP

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

  • Facility will cohort residents together who are colonized or infected with the same pathogen to confine their care to one area as well as to minimize contact and to prevent spread.

  • Facility will revise cohorting based on NYSDOH, CDC, and Local Epidemiologist as guidance becomes available and necessary.

See Policy on Cohorting in IP Manual

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

  • This 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 NYSDOH.

  • Residents will be transferred based on their infection status in accordance with applicable NYSDOH and CDC guidance.

  • All attempts will be made to have dedicated caregivers assigned to each Cohort group and to minimize the number of different caregivers assigned.

  • Facility will revise cohorting based on DOH and CDC guidance becomes necessary.

See Policy on Cohorting In IP Manual

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

  • This facility will follow the procedure on social distancing measures in accordance with State and CDC guidance to help control and prevent the spread of infections during outbreaks, including recreational activities and dining.

  • This facility will post signage indicating directives for social distancing as per NYSDOH and CMS guidance.

  • Residents and staff will be educated and monitored to maintain social distancing between peers.

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

  • Recovery services will focus on the needs of the residents and staff and help to restore the facility’s pre-disaster physical, mental social and economic conditions.

  • This 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.

  • This facility will maintain communication with the local NYSDOH and CMS and follow guidelines for returning to normal operations. 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.

Refer to Emergency Preparedness Manual, Section on Recovery


Additional Preparedness Planning Tasks for Pandemic Events

1. Develop/Review/Revise a Pandemic Communication Plan

  • The Administrator in conjunction with the Social Service Director will ensure that there is an accurate list of each resident’s Representative, and preference for type of communication.

  • Communication of a pandemic includes utilizing established Staff Contact List to notify all staff members in all departments.

  • Facility will update website and provide family notification on the identification of any infectious disease outbreak of potential pandemic.

  • Alternate methods of communications will be available for resident use

Refer to Section of PEP Additional Response Communication and Notifying Families/ Guardians and Weekly Update page 8

See Policy and Procedure on Communication During a Pandemic

Refer to list of Resident representatives/contact information

Refer to Staff Contact List located in EMP

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

  • Education of staff, residents, and representatives

  • Screening of residents

  • Screening of staff

  • Visitor Restriction as indicated and in accordance with NYSDOH and CDC

  • Proper use of PPE

  • Cohorting of Residents and Staff

See Infection Prevention and Control Policy and Procedures in IP Manual

Response Tasks for All Infectious Disease Events

1. Guidance, Signage, Advisories

  • This 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 Preventionist/Designee will ensure that appropriate signage is visible in designated areas for newly emergent infectious agents

  • The Infection Preventionist/Designee will ensure that appropriate signage is visible in designated areas to heighten awareness on cough etiquette, hand hygiene and other hygiene measures in high visible areas.

Refer to the CDC website for Signage download

2. 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 DNS/Infection Preventionist will be responsible to report communicable diseases via the NORA reporting system on the HCS on NHSN as directed by CMS.

3. Limit Exposure

  • 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.

  • Out on pass and follow up appointments will be restricted and limited based on NYSDOH and CDC guidance.

  • Facility will follow all guidance from NYSDOH regarding visitation, communal dining, and activities and update policy and procedure and educate all staff.

  • Hand sanitizer will be available on entrance to facility, exit from elevators, and according to NYSDOH and CDC guidance

See Policy on Cohorting In IP Manual

4. Separate Staffing

  • This 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.

See Policy on Emergency Preparedness /Hazards Staffing Guidelines

See Policy on Optimizing Utilization of Staff During a Pandemic

5. Conduct Cleaning/Decontamination

  • This 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.

See Policy on Terminal Cleaning in IP Manual

See Policy on Environmental Cleaning in IP Manual

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

  • This facility will provide updates to 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. Method of communication will be via telephone calls, mailings, robo calls, or facility website.

See Policy and Procedure on Communication During a Pandemic

7. Procedure on Advising 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 will advise visitors and vendors to limit/discontinue visits to reduce exposure risk to residents and staff.

  • Vendors and Consultants will be notified, in writing, by the Administrator/designee of pandemic practices and limitations to entry into the facility.   

  • 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.

  • This facility will implement closing the facility to new admissions in accordance with any NYSDOH directives relating to disease transmission

See Policy on Visitation during a Pandemic

Refer to Vendor Contact List in Emergency Manual

8. Limiting and Restriction of Visitation

  • This facility will limit and/or restrict visitors as per the guidelines from the NYSDOH

  • Residents and Representatives will be notified as to visitation restrictions and/or limitations as regulatory changes are made.

See Policy on Visitation during a Pandemic

Additional Response Tasks for Pandemic Events

1. Ensure Staff Are Using PPE Properly

  • 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.

  • Infection Control rounds will be made to monitor for compliance with proper use of PPE

See Policy on Surveillance in the IP Manual

See policy on PPE in IP Manual

2. Post a Copy of the Facility’s PEP

  • This 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.

  • A “hard copy” of document will remain available in the facility lobby, accessible by residents, families and staff. Additional copies can be provided, upon request.   

3. The Facility Will Update Family Members and Guardians

  • The Nursing Department will provide telephone updates, to authorized family members and guardians for residents infected with the pandemic infectious disease, daily, and upon changes to a resident’s condition.

  • Facility will provide weekly updates to all residents detailing the number of infections and deaths at the facility; 

  • Robo Calls and/or mail correspondence and/or phone calls will be provided updates to authorized family members and guardians, once per week, detailing the number of infections and deaths at the facility;

  • Staff will offer residents the use of cell phones, tablets etc.  to communicate, with authorized family members and/or guardian

  • This facility will communicate with Residents, Representatives as per their preference via, calls/robocalls and document all communication preference in the CCP/medical record.

  • Residents will be notified with regards to the number of cases and deaths in the facility unless they verbalize that they not wish to be notified. This will be documented in the medical record/CCP.

See Policy and Procedure on Communication During a Pandemic

Refer to CMS guidelines regarding a change in condition

4. The Facility Will Update Families and Guardians Once a Week – (See Section 3 Above)

5. Implement Mechanisms for Videoconferencing

  • This facility will provide residents with no cost, daily access to remote videoconference or equivalent communication methods with Representatives

See Policy and Procedure on Communication During a Pandemic


6. Implement Process/Procedures for Hospitalized Residents

  • This 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(i); and 42 CFR 483.15(e).

  • Prior to Admission/readmission the DNS/designee will review hospital records to determine resident needs and facility’s ability to provide care including cohorting and treatment needs.

See Policy on admissions/readmissions during a Pandemic

7. Preserving a Resident’s Place

  • This 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).

See Policy on admissions/readmissions during a Pandemic

See Policy and Procedure for Bed Hold During a Pandemic

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

  • This facility has implemented procedures to maintain at least a two-month (60 day) supply of PPE sufficient to protect health care personnel and residents.  The PPE will be stored in a safe and secure environment and will be audited to ensure the integrity of the 60 day PPE stockpile.

  • This facility will maintain contracts with vendors to secure PPE, as needed

  • PPE stockpile will be stored both on and off site

  • Supplies to be included, but not limited to, in the 60-day stockpile

    • N95 respirators

    • Face shield

    • Eye protection

    • Isolation gowns

    • Gloves

    • Masks

    • Sanitizer and disinfectants (meeting EPA Guidance current at the time of the pandemic)

See Policy and Procedure on Securing PPE

See Policy on Standard Precaution

Recovery of all Infectious Disease Events

1. Activities/Procedures/Restrictions to be Eliminated or Restored

  • This facility will focus on recovery services based on the needs of the residents and staff to restore the facility’s pre-disaster physical mental, social and economic conditions.  

See Emergency Preparedness Manual

2. Recovery/Return to Normal Operations

  • This facility will communicate any relevant activities regarding recovery/return to normal operations, with staff, families/guardians and other relevant stakeholders.

  • This 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.

  • This facility will screen and test outside consultants that re-enter the facility, as per the NYS DOH guidelines during the recovery phase.

See Emergency Preparedness Manual

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