Pandemic Emergency Plan

• This Pandemic Emergency Plan is prepared in accordance with the NYSDOH requirement as detailed in DAL NH 20-09 dated 8/20/20 and is added to and a component of Luxor Nursing & Rehabilitation at Mills Pond’s Emergency Preparedness Plan last reviewed and updated on January 8, 2023.
• The Pandemic Emergency Plan will be reviewed annually and modified as needed.
• The Pandemic Emergency Plan will be activated when a Pandemic is declared by either Federal (CMS or HHS) or State (NYSDOH) authorities.
• The SARS CoV2 (COVID-19) pandemic Public Health Emergency ended May 11, 2023.
• Next annual scheduled review date: January 8, 2024

Pandemic Emergency Preparedness Plan Availability  

1. An electronic copy of this Pandemic Emergency Plan (PEP) will be posted on the facility’s public website luxormillspond.com
2. A printed copy of this PEP will be available in the front lobby of the facility for families/visitors
3. Upon request, additional copies of this Pandemic Emergency Plan (PEP) will be provided

Resident Condition – Communication

4. The facility will update authorized family members and/or Health Care Proxy/Guardians of residents infected with a pandemic-related infection:
   1. At least daily and upon a change of condition
   2. The update will include the current medical condition and any noted changes in condition
   3. The facility will strive to accommodate specific family communication requests, including alternative communication methods
5. The facility will update families/responsible parties of residents at least once a week with the following information:
   1. Total number of residents currently infected with a pandemic-related infection
   2. Total number of resident deaths resulting from a pandemic-related infection
6. The weekly update will be conducted via posting on the facilities website on the same day each week before 5 pm
7. The facility will send a letter to families informing them about the scheduled weekly updates and instructions in how to access the website

Resident-Family communication

8. During a pandemic, as necessary, the facility will make available the following electronic devices to allow for regular communication between residents and family/responsible parties:
   1. Sufficient electronic tablets with video capability to allow residents and their families/responsible parties to have virtual visits via videoconferencing
   2. Internet connection
   3. A point person for the facility to schedule videoconferencing times and assist residents in accessing the video conference application
9. The facility will send a letter to families/responsible parties with pertinent details, including which video application is being used, the facility point person, and instructions in how to schedule a videoconference
   1. Electronic tablets will be kept in a secure location to ensure access and functionality
10. Electronic tablets and internet connection will be provided at no cost to residents or families/responsible parties

Family Stake Holder Education

11. The facility will post links to education material regarding the Pandemic Infectious Disease, e.g., Centers for Disease Control and Prevention – CDC)
12. The facility will post this PEP to allow families to see and review the facility’s response strategy

Infection Protection Plan

Infection Control Plan for Admission/Readmission

13. New Admissions and Readmissions (also see page 4 “readmitting”) from a hospital setting:
    1. Will be placed in transmission-based precautions based on current Federal and/or State guidance (whichever is most stringent)
    2. Will be closely monitored for signs and symptoms of pandemic-related infection
    3. Staff providing care will wear appropriate PPE per policy and as directed by NYSDOH
    4. Signs will be posted outside of resident rooms notifying/reminding staff to wear appropriate PPE, process for removing PPE, frequency, and importance of performing hand hygiene between each resident interaction
    5. To the extent possible, new admissions/readmissions will be cohorted together in one section of a unit, as recommended by Federal/State guidance, to minimize potential exposure (see Cohort Plan below for more details)

Cohort Plan

14. The facility may create cohort zones of dedicated rooms/units in order to reduce possible exposure and transmission, when recommended by Federal/state guidance.
15. The facility will determine the area of cohort zones based on the following:
    1. A cohort area may be a complete unit or a section of a unit depending on:
       1. The number of residents in each cohort at the time (this may change as infection rate changes)
       2. Facility layout/unit layout

• Bathroom availability

1. Staffing considerations

1. If only a small number of residents have the pandemic-related infection, those residents will be cohorted together in one area in a designated block of rooms to minimize exposure and transmission to others
2. Each cohort zone will have sufficient bathrooms for the residents residing in that zone
3. Residents will not be able to use bathrooms outside of their own zone

16. Cohort zones will be clearly designated (e.g., wall signage) to ensure employee compliance with appropriate PPE usage and prevention of unnecessary travel from one zone to another
17. Signs shall be posted in each zone indicating appropriate PPE usage as well as other important instructions
18. Doors shall be closed between units to prevent outside residents from entering other zones
19. If only one section of a unit is designated as a separate cohort zone, a visual barrier shall be placed alerting all to the separation
20. Staffing patterns developed for effective cohorting include:
    1. Minimize staff transfer between cohorting zones, wherever possible
    2. Bundle care of residents in same cohort zone before moving on to another zone
    3. Establish a PPE donning and doffing process and competency
    4. Ensure sufficient hand hygiene (e.g., soap and water facilities, alcohol-based hand rub) and appropriate EPA registered disinfectant between cohorting zones

Managing Cohort Zones

21. Utilize the infection control electronic bed board (color coded for each zone) to enable efficient tracking and cohorting of residents
22. Cohorting review process
    1. A resident who has symptoms or is diagnosed with a pandemic-related infection will be immediately transferred to a positive zone
    2. A roommate of newly infected resident will be placed in transmission-based precautions and monitored closely for signs and symptoms, per current Federal and/or State guidance
    3. The electronic bed board will be utilized to track and manage transmission-based precautions duration, and will be reviewed and updated daily
    4. Changes in cohorting and resident room moves will proceed follow the daily review of the electronic bed board
23. Resident transfer process:
    1. Both resident rooms will be disinfected before and after transfer
    2. Plastic trash bags will be used to cover and secure resident belonging to prevent transmission of infection during the transfer
    3. Nurse to nurse handoff communication will occur between each resident transfer
    4. Medication reconciliation will occur with each resident transfer
    5. The electronic bed board and resident’s electronic health record will be updated to reflect room changes
24. In case of an emergency or significant outbreak where the facility cannot maintain cohorting zones, the facility will:
    1. Contact corporate clinical and operational support to secure increased staffing, supplies, or other such items necessary to maintain care and proper cohort at the facility
    2. Contact sister facilities for staff and/or supplies
    3. If after all support options are exhausted, the facility will contact NYSDOH and local county DOH for support and further guidance

Social Distancing – Reducing potential exposure

25. The facility will follow Federal/State guidance regarding transmission and any social distancing necessary to reduce potential exposure to the infectious pandemic outbreak. These guidelines may include but not be limited to:
    1. Suspend communal dining and activities, per NYSDOH and CMS guidance/regulations
    2. Establish protocols for resident transfers
    3. Outdoor activities, such as smoking, limited to only a few residents at a time to allow for social distancing between residents
    4. Where possible, place indicators such as stickers to indicate social distancing measurements
    5. Employee breakroom will be limited to allow for social distancing
    6. Employees will be provided education to maintain social distancing even while on break

Readmitting Hospitalized Residents  

26. In accordance with applicable NYS DOH and Federal Bed-Hold regulations and the facilities Bed-Hold polices, during a pandemic the facility will assure residents who are hospitalized due to the pandemic disease will be readmitted to the facility when:
    1. Their level of care can be safely managed at the facility
    2. There is an appropriate bed available taking into account:
       1. Positive infections and cohorting zones
       2. Specialized care units

• Behavior/locked units

27. The facility will inform the hospitalized residents and families/responsible parties of this policy together with the regular bed hold policy which is provided to residents and families
28. In accordance with applicable NYS and Federal Bed-Hold regulations and the facilities Bed-Hold polices, during a pandemic the facility will attempt to preserve the resident’s place/room, if appropriate:
    1. Admit new residents to other open beds first, taking into account the following:
       1. Gender – roommate and shared bathroom (between rooms) considerations
       2. Infection prevention and control (including other infections) and cohorting considerations

• Psychosocial considerations

29. Returning resident readmissions will return to their prior room location following Federal/State guidance in response to the pandemic infectious illness.

Securing a 60-day supply of PPE

30. Ensure minimum of 60-day supply of Personal Protective Equipment (PPE) is available:
    1. Review current supply and average daily usage of PPE with the Director of Nursing and Medical Director
    2. Review NYSDOH guidance for PPE usage and regulations
    3. Review the CDC PPE burn rate calculator, as provided during the SARS CoV2 pandemic as a guide for future PPE needs
    4. Arrange for a minimum of 60-day stockpile of PPE which may include but not be limited to:
       1. N95 respirators
       2. Face shield

• Eye protection

1. Gowns/isolation gowns
2. Gloves
3. Masks

• Hand sanitizer
• EPA registered disinfectants

1. Identify a secure location for storage of PPE
   1. Secure Location __________________________________________
   2. Secure Location (2) _______________________________________ (if needed)

• Secure Location (3) _______________________________________ (if needed)

1. Establish regular weekly delivery service of depleted PPE supply in order to preserve a 60-day supply
2. Establish protocols for supply rotation (e.g., first-in first-out)
3. Arrange for back-up delivery services in case of supply or logistical disruption of the regular supply chain
4. PPE burn rate may be pathogen specific, including item specific. Review DOH guidance and observed usage to modify burn rate calculation to ensure sufficient PPE supply. 

Staff education on infectious diseases

31. The facility will provide education for employees on the following:
    1. Infection prevention and control – Basic prevention of communicable diseases
    2. Pandemic-related specific infection prevention and control
    3. Risk of exposure/transmission and need for PPE use along with hand hygiene guidance
    4. PPE guidance and usage
       1. Proper technique for donning and doffing
       2. Level of appropriate PPE

• Proper use of hand hygiene (e.g., use of hand sanitizer, hand hygiene using soap and water)

1. Housekeeping and disinfection process
2. Pandemic infectious disease signs and symptoms
3. As applicable, regulations pertaining to the pandemic infectious disease, including but not limited to:
   1. Travel restrictions
   2. Health screening requirements

• Testing requirements

1. PPE requirements
2. Social distancing for staff and residents
3. Restriction of visitation

32. Regulatory reporting requirements for the pandemic infectious disease
33. The facility will provide education as described above to newly hired staff at the time of orientation
34. Infection Prevention and Control posters will be displayed in key locations throughout the facility reminding/educating staff regarding:
    1. Hand hygiene
    2. PPE use
    3. PPE Donning and Doffing
    4. Other infection prevention and control guidelines, based on Federal/State guidance and the specific pandemic infectious disease
35. The facility will develop cleaning and disinfecting practices related to the Pandemic Infectious Disease
36. The facility will provide education to housekeeping staff on the cleaning and disinfection methods and products necessary to maintain environmental infection prevention and control safety as related to the Pandemic Infectious Disease

Communicable Disease Reporting

36. The Administrator, Director or Nursing, and Infection Preventionist will review reporting requirement for suspected or confirmed communicable diseases as mandated under NYSDOH Regulated Article 28, New York State Sanitary Code (10 NYCRR 2.10 Part 2), as well as by 10 NYCRR 415.19.
37. See Annex K of the CEMP toolkit for complete reporting requirements including a list of diseases
38. The facility will ensure the following staff members have access to Health Commerce System (HCS), Nosocomial Outbreak Reporting Application (NORA), and HERDS surveys:
    1. Administrator
    2. Assistant Administrator
    3. Director of Nursing
    4. Infection Preventionist
    5. Assistant Director of Nursing
39. The facility will provide education to the above listed staff members on the reporting requirements and specific reporting methods for NORA, HERDS, and NHSN reports
40. The DON/Infection Preventionist will be responsible to report communicable diseases via the NORA reporting system on the HCS
41. The Administrator will be responsible to complete required HERDS survey reporting
42. The Administrator will arrange and train an alternate staff member to complete the HERDS survey reporting, as necessary
43. Should personnel changes occur, the replacement staff member will be provided with log-in access and training for HCS, NORA, and HERDS Survey applications
44. Cases, including a single case of a communicable or unusual (novel) disease, will be reported to the local county health department (LHD) per state and LHD time requirements.

NYSDOH and CMS Updates

45. The facility will review NYS DOH and CMS Pandemic related updates through:
    1. Regular checks of the HCS website for updates
    2. Regular checks or CMS website for updates
    3. Registration for email updates from HCS and CMS
    4. Regular checks of industry communication websites

Develop/Review/Revise and Enforce existing infection prevention, control, and reporting policies.

46. The facility will develop a comprehensive Pandemic Infectious Disease Plan which includes sections addressing:
    1. Infection prevention techniques, policies, and procedures
    2. Infection control techniques, policies, and procedures
    3. Cohorting policies and procedures
    4. Local, State, and Federal reporting guidelines
    5. Cleaning and disinfecting techniques, policies, and procedures
47. The facility will review the Pandemic Infectious Disease Plan annually and as needed and will revise as needed

Conduct routine/ongoing, infectious disease surveillance

48. Based on Federal/State requirements for the pandemic infectious disease, the facility will:
    1. Test employees, including agency staff and vendors on a frequency required by the NYSDOH or CMS
    2. Screen employees, including agency staff and vendors, upon entry to the facility
    3. Establish a resident assessment tool for early dedication of signs and symptoms of the pandemic infectious disease
    4. Maintain a Pandemic Infectious Disease infection control line listing and tracking tool to monitor rates of infection

Plan for staff testing and laboratory services

49. The facility will:
    1. Utilize an electronic tracking tool for employee and residents testing and will audit tracking and testing compliance weekly or as recommended by Federal or State guidance.
    2. Contract with a diagnostic lab capable of handling the frequency of testing required, including the receipt of timely results as required by NYSDOH or CMS
    3. Establish drop-off and/or shipping processes for lab tests, as applicable

Ensure sufficient supply of medications, environmental cleaning agents, food, water, and PPE

Sufficient medications

50. The facility will:
    1. Review Pharmacy delivery protocols with a pharmacy representative to ensure uninterrupted supply of medications during a pandemic
    2. Develop a contingency plan with the pharmacy for alternate delivery methods or schedules in case of travel restrictions due to a pandemic
    3. Review residents’ medication regimen with the Medical Director to identify medications that can be reduced or stopped in case of medication shortages as a result of a pandemic
    4. Review residents’ medication regimen with the Medical Director to identify vital medications
    5. Plan with the pharmacy for a 4 to 6-week stockpile for those identified vital medications
    6. Identify a secure location for storage of those medications
       1. Secure Location Nursing Office

Sufficient environmental cleaning agents and other supplies (i.e. toilet paper, tissues, linen)

51. The facility will:
    1. Review current supply and weekly usage of environmental cleaning agents with the Director of Housekeeping and Laundry and Director of Dietary (for kitchen cleaning/disinfection agents)
    2. Review with the Medical Director additional environmental cleaning/disinfection agents needed as a result of the Pandemic. Review EPA registered products specifically designed to kill the pandemic infectious disease.
    3. Review current supply and weekly usage of all standard non-medical supplies
    4. Calculate and purchase sufficient amounts of products to equal a 30-day supply
    5. Identify a secure, safe, location for storage of environmental and dietary chemical products
       1. Secure Location Housekeeping Storage Room
    6. Develop a contingency plan with environmental, dietary cleaning/disinfection agents and non-medical supply vendors in case of travel restrictions due to a pandemic

60-day supply of Personal Protective Equipment (PPE)

52. See “Securing a 60-day supply of PPE” on Page 4

Sufficient food and water

53. The facility will:
    1. Review with the Food Service Director (FSD) the current amount of food and water stored at the facility
    2. Ensure there is a minimum of 3 days’ supply of food and water available
    3. Develop a contingency plan with the food vendor for alternate delivery methods or schedules in case of travel restrictions due to a pandemic
    4. Identify a second vendor for emergency use

Administrative controls to help prevent infection at the facility

Facility Visitation

54. The facility will follow NYSDOH, CMS, and CDC guidance regarding family/friends’ resident visits
    1. If directed by NYSDOH or CMS during a pandemic infectious illness – halt visits except end of life
       1. Notify families of the new/updated guidance
       2. Set up electronic video conference for virtual visit (see Page 1)
    2. When NYSDOH allows the resumption of visits, the facility will
       1. Develop a safe visitor policy and procedure
       2. Develop a visitor health screen tool per NYSDOH, CMS, and CDC guidance, if applicable
       3. Initiate an electronic record of visitors to allow for contact tracing in case of a subsequent outbreaks
       4. Implement social distancing plans and determine daily maximum allowance of visitors
       5. Halt visits if a resident or facility employee tests positive or is diagnosed with the Pandemic Infectious Disease or as directed by NYSDOH or CMS as a result of an increase in local community infection rates
       6. See Page 9 for resumption and recover to normal (pre-pandemic) operations

Staff Screening

56. Initiate a comprehensive staff health screening tool
57. Follow NYSDOH CMS and CDC guidance regarding staff health screens
58. Set up a central location for staff entry to ensure staff are screened prior to beginning work

Emergency Staffing

59. Create an emergency staffing contingency plan which includes, but not limited to:
    1. Contacting outside nursing support agencies to alert them of a pending need
    2. Contacting corporate staffing support to identify sister facilities who have the ability lend staff in an emergency
    3. Follow an emergency staffing ADL care schedule to guide nursing staff in how to prioritize ADL care during a severe staffing situation
    4. Provide emergency training of non-clinical staff.
       1. Develop a work flow, following and working alongside clinical staff in meeting non-personal care needs (e.g., making beds, wheeling residents to dining, passing food trays, answering call lights, etc.)

New Admissions

60. If as a result a pandemic the NYSDOH or CMS directs the facility to stop new admissions, the facility will:
    1. Inform hospital(s) and other discharge locations of the new order
    2. Inform admissions and marketing staff to halt admissions

Environmental controls

61. The facility will:
    1. Review contract with the licensed vendor for contaminated waste disposal to ensure it is current
    2. Assess areas for contaminated waste are clearly identified as per NYSDOH guidelines
62. The facility will follow Department of Environmental Conservation (DEC) and DOH regulations for the handling of contaminated waste.
63. The onsite storage of waste shall be labeled and in accordance with regulations.
64. Staff involved in handling of contaminated materials shall be trained in procedures prior to performing tasks and shall be provided proper PPE when handing contaminated materials
65. The facility will amend policy and procedure on biohazardous wastes as needed related to new, novel, infectious agents.

Develop a plan to recover/return to normal operations

66. The facility will adhere to regulations and directives as specified by NYSDOH, CMS, and CDC at the time of each specific infectious disease or pandemic event regarding how, when, which activities/procedures/restrictions may be eliminated or restored, and the timing of when those changes may be executed.
67. The facility will maintain communication with the NYS DOH and CMS and will follow guidelines for returning to normal operations which include, but may not be limited to.
    1. Regular checks of the HCS website for updates
    2. Registration for email updates from HCS and CMS
68. The decision to resume outside consultant visits will be made through collaboration and direction from the NYSDOH and will be based on a case-by-case basis taking into account medical necessity and infection levels in the community.
69. The decision to resume family/friend visitation will be made through collaboration and direction from the NYSDOH and will be based on a case-by-case basis taking into account medical necessity and infection levels in the community.
70. Families, responsible parties, and guardians will be notified of impending visitation changes, recovery, and return to normal operations via electronic notification on the facilities website.

During the recovery period, monitoring of residents and staff will continue in order to identify signs and symptoms which may be related to the Pandemic Infectious Disease.