Queens Nassau

(Infectious Disease) Pandemic Emergency Plan (PEP)

As the COVID-19 pandemic surged around the world, healthcare policymakers, 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 settings 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 nursing home.

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 and mode of transmission. Infectious disease emergencies can include outbreaks, epidemics and pandemics.

The Local Health Department (LHD) of each New York State county, maintains prevention agenda priorities compiled from community health assessments. Queens Nassau Nursing Home 🏠 has used this information in conjunction with an internal risk assessment to create their plan and to set priorities, policies and procedures.

The following Infectious Disease/Pandemic Emergency Plan (PEP) outlines the preparedness, response, and recovery strategies that Queens Nassau 🏡 has that are unique to an incident involving all types of infectious diseases, including those that rise to the higher level of pandemic emergency i.e. Covid 19. It lays out the required elements of new legal and regulatory responsibilities during an infectious disease and/or pandemic incident.

(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 Inservice Coordinator/Designee, will 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. Training includes pandemic exposure risk, symptoms, preventions & PPE.
  • The IP/ Designee will conduct annual competency-based education on hand hygiene and donning/doffing Personal Protective Equipment (PPE) for all staff.
  • The IP in conjunction with the Inservice 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.

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 including surveillance, investigation/reporting, management of resident & staff infections, PPE use, handwashing & Housekeeping protocols.
  • The Facility will update the Infection Control Manual, which is available in 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.

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 quarterly basis or as needed, so as to identify any tends and areas for improvement.
  • Infection surveillance line listings are developed for Resident & Staff infections and monitored by infection preventionist/ designee.
  • At daily Morning Meeting, the IDT team will identify any issues regarding infection control and prevention.
  • As needed, the Director of Nursing (DON)/Designee will establish Quality Assurance Performance Projects (QAPI) to try 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 committee.
  • All staff are to receive annual education as to the need to report any change in resident condition to supervisory staff for follow up.
  • Staff will identify the rate of infectious diseases and identify any significant increases in infection rates and will be addressed.
  • Facility acquired infections will be tracked/reported by the Infection Preventionist.

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 agent.
  • Routine Staff testing implemented as per Executive order 202 – by community level. See table below.
  • Routine Testing Intervals Vary by Community COVID-19 Activity Level
Community COVID-19 Activity County Positivity Rate in the past week Minimum Testing Frequency
Low <5% Once a month
Medium 5% – 10% Once a week*
High >10% Twice a week*

*This frequency presumes availability of Point of Care testing on-site at the nursing home or where off-site testing turnaround time is <48 hours.

    • Covid Staff & Resident testing protocol implemented per DOH requirements. 1 positive infection requires testing of all staff & residents (excluding previous positives).
    • When prioritizing individuals to be tested, facilities should prioritize individuals with signs and symptoms of COVID-19 first, then perform testing triggered by an outbreak as specified in table below.
    • For outbreak testing, all staff & residents should be tested. All staff and residents that tested negative should be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result.
    • Testing summary:
Testing Trigger Staff Residents
Symptomatic individual identified Staff with signs and symptoms must be tested Residents with signs and symptoms must be tested
(Any new case arises in facility)
Test all staff that previously tested negative until no new cases are identified* Test all residents that previously tested negative until no new cases are identified*
Routine testing >According to Table 2 below Not recommended, unless the resident leaves the facility routinely.
        • The facility shall have prearranged agreements with laboratory services to accommodate any testing of residents and staff including consultants and agency staff. 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 guidance.

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 NYSDOH.
            • The following Staff Members have access to the NORA and HERDS surveys: Administrator, Director of Nursing, Infection Preventionist, and Assistant Director of Nursing. 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 Director of Nursing/designee will enter any data in NHSN as per CMS/CDC guidance.

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

            • The Medical Director, Administrator, 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.
            • The facility has established par Levels for Environmental Protection Agency (EPA) approved environmental cleaning agents based on pandemic usage.
            • The facility has established par Levels for PPE for 60 day supply.

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 agent. 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.
            • Visitors must have a negative test within past 7 days.
            • Any visitors with Covid symptoms will not be permitted to visit.
            • Visitors will be provided with a Covid self test kit as required by DOH.
            • No visitors under 16 years of age without an adult accompanying them
            • 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.

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 review/revise the Policy and Procedure on Biohazardous wastes as needed related to any new infective agents.

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 available. This is monitored on a quarterly basis to ensure that it is intact and safely stored.
            • Vendor agreements will be obtained.
            • The facility has adequate supply of stock medications for 4-6 weeks.
            • The facility has access to a minimum of 2 weeks supply of needed cleaning/sanitizing agents in accordance with storage and NFPA/Local guidance. The supply will be checked each quarter and weekly as needed during a Pandemic.
            • Department heads responsible for monitoring the supply will report to Administrator/designee or Director of Nursing/designee any specific needs and shortages.

10. Develop a plan to Ensure Residents are Cohorted based on their Infectious Status in accordance with applicable NYSDOH and Centers for Disease Control guidance (R)

            • 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 Facility will dedicate a unit, or group of rooms at the end of a unit, or a section part of a unit in order to Cohort residents. This area will be clearly demarcated as isolation area.
            • The Cohort will be divided into three groups: Unknown, Negative, and Positive as it relates to the infectious agent.
            • Red Zone = Positive, Yellow Zone = unknown, Green Zone = negative. These zones are clearly demarcated.
            • The resident will have a comprehensive care plan developed indicating their Cohort Group and specific interventions needed.
            • 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 Group.
            • 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 paper work.
            • All attempts will be made to have dedicated caregivers assigned to each Cohort group and to minimize the number of different caregivers assigned.

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

            • The facility will review/ revise the Policy on Communal Dining Guidelines during a Pandemic to ensure that Social Distancing is adhered to in accordance with State and CDC guidance. Communal dining will be suspended.
            • 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 resident.
            • The facility will ensure staff break rooms and locker rooms allow for social distancing of staff.
            • All staff & Residents will be re-educated on these updates as needed.
            • Signage throughout the building to remind of Social Distancing.

12. 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.
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 and the dedicated facility phone line (extension 311), 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

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
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 Preventionist/Designee will ensure that clear appropriate signage are posted & visible in designated areas to heighten awareness on cough etiquette, hand hygiene and other hygiene measures in high visible areas.

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 415.19.
            • Any suspected or identified case of communicable disease will be reported immediately to Medical Director, Infection preventionist, DON/designee.
            • The DON/Infection Preventionist/designee will be responsible to report Daily HERDS report.
            • The DON/Infection Preventionist/designee will be responsible to report Weekly reporting.
            • The DON/Infection Preventionist/designee will be responsible to report communicable diseases via the NORA reporting system on the HCS
            • The DON/Infection Preventionist/designee will be responsible to report communicable diseases on NHSN as directed by CMS (CDC).
            • Local Epidemiologist will be consulted for guidance if possible.

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

            • Signage will be posted at Front entrance and all high traffic areas regarding use of PPE, visitation restrictions, hand hygiene & social distancing.

4. Limit Exposure

            • The facility will make best effort 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 make best effort to cohort residents according to their infection status.
            • The Cohort will be divided into three groups: Unknown, Negative, and Positive as it relates to the infectious agent.
            • Red Zone = Positive, Yellow Zone = unknown, Green Zone = negative. These zones are clearly demarcated.
            • Facility will monitor all residents to identify symptoms associated with infectious agent.
            • Units will be quarantined in accordance with NYSDOH and CDC guidance and if possible separate staffing provided.
            • Facility will follow all guidance from NYSDOH regarding visitation, communal dining, and activities and update policy and procedure and educate all staff.
            • Any symptomatic or infected staff will be sent home and furloughed. Return to workl after appropriate 14 day quarantine period.
            • 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.

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 increased 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 (R)

            • The facility will 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 who can comprehend 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 (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 – front lobby – to avoid going all over 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 (R)

            • The facility will limit and or restrict visitors as per the guidelines from the NYSDOH with signage posted.
            • Residents and Representatives will be notified as to visitation restrictions and/or limitations as regulatory changes are made.
            • All care vendors/ contractors suspended unless deemed medically necessary.
            • Any visitors with Covid symptoms will not be permitted to visit.
            • Visitors will be provided with a Covid self test kit as required by DOH.
            • No visitors under 16 years of age without an adult accompanying them
Additional Response Tasks for Pandemic Events

1. Ensure Staff Are Using PPE Properly

            • The facility has a Respiratory Protection Plan in progress.
            • Appropriate signage shall be posted at all entry points, and on each residents’, door indicating the type of transmission-based precautions that are needed.
            • Droplet precautions/isolation procedures reviewed & revised as necessary.
            • Staff are inserviced annually and as needed in droplet precaution/isolation procedures.
            • 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/designee to monitor for compliance with proper use of PPE
            • The facility has adequate and available PPE accessible on all shifts.
            • Staff are educated to report any PPE issues to their immediate Supervisor

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

            • Queens Nassau Nursing Home will post a copy of the facility’s PEP by September 15, 2020 in a form acceptable to the commissioner on the facility’s public website and make available immediately upon request.
            • Public access to website: queensnassaurehab.com
            • The PEP plan will be available for review and kept in a designated area in nursing office.

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

            • During a Pandemic, the facility will communicate with Residents, Representatives as per their preference i.e. Email, text messaging, calls/robocalls, website, dedicated facility phone extension (311), and document all communication preference in the CCP/medical record.
            • Daily updates posted on the facility website related to the number of active staff and resident cases as well as total number of suspected resident deaths related to Covid 19.
            • Monthly mailings to resident representative.
            • Daily update to facility phone extension 311 for Covid information updates.
            • Daily phone calls with update of resident condition for any affected resident.
            • Notification to be made when a resident experience a change in condition.
            • 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
            • Any residents at their request will be provided with daily access to communicate with their representatives. The type of communication will be as per Family/Representative’s preference i.e. video conferencing/telephone calls, and/or email.

4. 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 Family/Representatives.
            • Facetime or Google Duo or other similar means via IPAD’s or similar devices will be utilized.
            • The Director of Recreation/Designee will arrange for the time for all videoconferencing.
            • Communication will be by electronic means or other method selected by each family member/representative & resident.

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

            • The facility has 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 (R)

            • The facility has 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).
            • 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.

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 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.
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.

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


Posted 9-15-2020

Updated: 7-18-22