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Response Tasks for All Infectious Disease Events 

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

  • The Infection Control Practitioner will be responsible to ensure that there are clearly posted signs for cough etiquette, hand washing, and other hygiene measures in high visibility areas.  

  • 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. 

 

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 DON/Infection Preventionist will be responsible to report communicable diseases via the NORA reporting system on the HCS 

  • The DON/Infection Preventionist will be responsible to report communicable diseases on NHSN as directed by CMS. 

 

3. Signage  

 

4. 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. 

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5. Separate Staffing  

  • 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.  

 

6. 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.  

 

7. 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. 

 

8. Policy and Procedures for Minimizing Exposure Risk (Refer to section 4) 

  • 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.  

  • 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. 

 

9. Advise 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. 

  • 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  

 

10. Limiting and Restriction of Visitation 

  • The 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. 

 

Additional Response Tasks for Pandemic Events  

1. 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. 

  • Infection Control rounds will be made by the DON, IP, 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  

 

2. 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 and kept in a designated area with the most recent NYS DOH survey results. 

 

3. 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 daily by Nursing staff as to the resident’s status.  

  • Representatives will be notified when a resident experience a change in condition 

  • Representatives will be notified weekly on the status of the pandemic at the facility including the number of pandemic infections. 

  • The Hotline message will be updated within 24 hours indicating any newly confirmed cases and/or deaths related to the infectious agent. 

  • Residents will be notified 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 

  • 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. 

 

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

 

5. Implement Mechanisms for Videoconferencing 

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

  • The Director of Recreation/Designee will arrange for the time for all videoconferencing 

 

6. Implement Process/Procedures for Hospitalized Residents 

  • The 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 DON/designee will review hospital records to determine resident needs and facility’s ability to provide care including cohorting and treatment needs. 

 

7. Preserving a Resident’s Place 

  • 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).  

 

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

  • 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 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   

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