Park Terrace Care Center

Park Terrace Infection Control Pandemic Emergency Plan


Annex E: Infectious Disease/Pandemic Emergency

As the COVID-19 pandemic surged around the world, healthcare policy makers, management and staff have had to recognize a risk that was talked about, but never really prepared for. Complicating the response further was that this pandemic was caused by a new pathogen, (novel virus), and to which there was no natural immunity or vaccination. We are still learning about how this disease is transmitted, which population is the most vulnerable and the best course of treatment. The most terrible aspect of the experience so far is that COVID-19 takes a terrible toll on the elderly and those sick with co-morbidities. As such, Skilled Nursing Facilities congregate care setting were especially at risk during this outbreak. As a result of this, the State and Federal governments have enacted additional requirements for the safe operation of a home. This document lays out the required elements of new legal and regulatory responsibilities during a pandemic.


(R) = Required Element

* NYSDOH regulation indicates both required and recommended elements need to be addressed in PEP


Preparedness Tasks for all Infectious Disease Events

1.     Staff Education on Infectious Diseases (R)

  • The Facility Infection Preventionist (IP) in conjunction with lnservice Coordinator/Designee, must provide education on Infection Prevention and Management upon the hiring of new staff, as well as ongoing education on an annual basis and as needed should a facility experience the outbreak of an infectious disease.
  • The IP/ Designee will conduct annual competency-based education on hand hygiene and donning/doffing Personal Protective Equipment (PPE) for all
    • The IP in conjunction with the lnservice Coordinator will provide in-service training for all staff on Infection Prevention policies and procedures as needed for event of an infectious outbreak including all CDC and State updates/guidance.

Refer to Policy and Procedure: Infection Prevention Staff Training


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

The facility 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 facility management will consult 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.

Refer to Facility Assessment for Attestation of Yearly Review or Paper Copy with Signature Review Sheet


3.     Conduct Routine/Ongoing, Infectious Disease Surveillance

  • The Quality Assurance (QA) Committee will review all resident infections as well as the usage of antibiotics, on a monthly basis so as to identify any tends and areas for improvement.


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  • At daily Morning Meeting, the IDT team will identify any issues regarding infection control and
  • As needed, the Director of Nursing (DON)/Designee will establish Quality Assurance Performance Projects (QAPI) to identify root cause(s) of infections and update the facility action plans, as appropriate. The results of this analysis will be reported to the QA
  • All staff are to receive annual education as to the need to report any change in resident condition to supervisory staff for follow
  • Staff will identify the rate of infectious diseases and identify any significant increases in infection rates and will be
  • Facility acquired infections will be tracked/reported by the Infection

Refer to Policy and Procedure: Infection Control Surveillance


4.     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
  • The facility shall have prearranged agreements with laboratory services to accommodate any testing of residents and staff including consultants and agency 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.
  • Administrator/ DON/Designee will check daily for staff and resident testing results and take action in accordance with State and federal

Refer to Vendor List in Emergency Management Plan (EMP) Refer to PIP Testing


5.     Staff Access to Communicable Disease Reporting Tools (R)

  • The facility has access to Health Commerce System (HCS), and all roles are assigned and updated as needed for reporting to
  • The following Staff Members have access to the NORA and HERDS surveys: Administrator, Director of Nursing, Infection Preventionist, and Assistant Director of 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

Refer to Annex K Section 1 Communicable Disease Reporting Refer to Facility Assessment


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

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






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

Refer to Policy and Procedure on Personal Protective Equipment: Par Level, Storage and Calculating Burn Rate

Refer to Policy and Procedure on Environmental Cleaning Agents

Refer to Vendor list and Contracts in EMP (Emergency Management Plan)


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

  • All sick calls will be monitored by Department Heads to identify any staff pattern or cluster of symptoms associated with infectious Each Dept will keep a line list of sick calls and report any issues to IP/DON during Morning Meeting. All staff members are screened on entrance to the facility to include symptom check and thermal screening.
  • Visitors will be informed of any visiting restriction related to an Infection Pandemic and 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 The staffing plan includes collaboration with local and regional DOH planning and CMS to address widespread healthcare staffing shortages during a crisis.

Refer to Policy and Procedure: Visitation Guidelines during Pandemic

Refer to Policy and Procedure Staff Screening and Monitoring During a Pandemic. Refer to contingency staffing plan in EMP


8.     Develop/Review/Revise Environmental Controls related to Contaminated Waste (R)

  • 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.
  • The facility will amend the Policy and Procedure on Biohazardous wastes as needed related to any new infective agents.

Refer to Policy and Procedure on Handling of Biohazardous Waste Material


9.     Develop/Review/Revise Vendor Supply Plan for food, water, and medication (R)

  • The facility currently has a 3-4 days’ supply of food and water This is monitored on a quarterly basis to ensure that it is intact and safely stored.
  • The facility has adequate supply of stock medications for 4-6

The facility has access to a minimum of 2 weeks supply of needed cleaning/sanitizing agents in accordance with storage and NFPA/Local The supply will be checked each quarter and weekly as needed during a Pandemic. A log will be kept by the Department head responsible for monitoring the supply and reporting to Administrator any specific needs and shortages.

Refer to the following

PIP Subsistence Food and Water EMP

Facility Logs: Water and Food: Food Service Director Stock Medications: Director of Nursing

Sanitizing/Cleaning Agents: Director of Environmental Services


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

  • Residents are isolated/cohorted based on their infection status in accordance with applicable NYSDOH and Centers for Disease Control guidance.
  • The facility Administration 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.
  • The Cohort will be divided into three groups: Unknown, Negative, and Positive as it relates to the infectious
  • The resident will have a comprehensive care plan developed indicating their Cohort Group and specific interventions

Refer to Policy and Procedure on Cohorting


11.  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
  • 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 paperwork.
  • All attempts will be made to have dedicated caregivers assigned to each Cohort group and to minimize the number of different caregivers

Refer Policy and Procedure Cohorting Guidelines during a Pandemic

Refer Policy and Procedure Transferring Residents with Infection Diseases.


12.  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
  • 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
  • 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 4jPage



Refer to Policy and procedure: Dining Guidelines during a Pandemic Refer to Policy and procedure: Recreation Needs During a Pandemic


13.  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.

Refer to Policy and Procedure Staff Monitoring during a Pandemic Emergency

Refer to Policy and Procedure Resident Monitoring during the Recovery phase of a Pandemic Emergency


Additional Preparedness Planning Tasks for Pandemic Events

1.     Develop/Review/Revise a Pandemic Communication Plan (R)

  • 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.
  • The Facility will update website on the identification of any infectious disease outbreak of potential pandemic.

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

Refer to Policy and Procedure Communication with Residents and Families During 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 (R)

  • 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

Refer to Infection Prevention and Control Policy and Procedures


Response Tasks for All Infectious Disease Events

1.     Guidance, Signage, Advisories




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  • 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
  • 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
  • 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

Refer to the attached listing of government agencies and contact numbers Refer to the CDC website for Signage download


2.     Reporting Requirements (R)

  • 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 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.

Refer to Annex K CEMP for reportable diseases


  1. Signage (Refer to Guidance, Signage, Advisories)


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
  • 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.

Refer Policy and Procedure Cohorting Guidelines during a Pandemic

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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.

Refer to Policy and Procedure on Cohorting


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.

Refer to Environmental Cleaning /Disinfection PIP

Refer to the attached Policy and Procedure on Terminal Room Cleaning


7.     Educate Residents. Relatives. and Friends About the Disease and the Facility’s Response (R)

  • 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

Refer to the attached Policy and Procedure on Communication During a Pandemic


  1. 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
    • 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.

Refer to Memo regarding vendor delivery during a Pandemic Refer to PIP Telehealth Services


9.     Advise Vendors, Staff, and other stakeholders on facility policies to minimize exposure risks to residents (R)

  • 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.

Refer to Policy and Procedure on Visitation during a Pandemic

Refer to Policy and Procedure on Limited Services During a Pandemic


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Refer to Vendor Contact List in EPM


10. Limiting and Restriction of Visitation (R)

  • 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.

Refer to Policy and Procedure on Visitation during a Pandemic


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 resident’s, 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.

Refer to Policy and Procedure on Respiratory Protection Program Refer to Infection Control Surveillance Audit

Refer to PIP on PPE


2.     Post a Copy of the Facility’s PEP (R)

  • 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 (INSERT)

Refer to attestation that PEP will be readily available


3.     The Facility Will Update Family Members and Guardians (R)

  • 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 This will be documented in the medical record/CCP

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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.

Refer to Policy and Procedure Communication with Residents and Families During Pandemic Refer to CMS guidelines regarding a change in condition


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


5.     Implement Mechanisms for Videoconferencing (R)

  • 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

Refer to Policy and Procedure Communication with Residents and Families During Pandemic Refer to P and P on Recreational Needs of Residents during a Pandemic


6.     Implement Process/Procedures for Hospitalized Residents (R)

  • 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 41S(i); and 42 CFR 1S(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.

Refer to Policy and Procedure for Bed Hold During a Pandemic


7.     Preserving a Resident’s Place (R)

  • 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 9(d)(6) and 42 CFR 483.1S(e).

Refer to 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) (R)

  • 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
  • This includes, but is not limited to:
  • N95 respirators
  • Face shield
  • Eye protection

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  • 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

Refer to Policy and Procedure on Securing PPE

Refer to Vendor Contract List including information for Local and State OEM in EPM


Recovery of all Infectious Disease Events

1.     Activities/Procedures/Restrictions to be Eliminated or Restored (R)

  • 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.

Refer to Pandemic Tracking Sheet


2.     Recovery/Return to Normal Operations (R)

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

Refer to Policy and Procedure: Staff Testing during Pandemic





















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