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Isabella Center Pandemic Response Plan (PEP)

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Isabella Center for Rehabilitation and Nursing Care
Pandemic Emergency Plan (PEP)

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. The facility must plan effective strategies for responding to all types of infectious diseases, including those that rise to the higher level of pandemic.

Infectious diseases are caused by pathogenic microorganisms, such as bacteria, viruses, parasites, or fungi. The circumstances of infectious disease emergencies, including ones that rise to the level of a pandemic, vary by multiple factors, including type of biological agent, scale of exposure, mode of transmission and intentionality.

Under the Pandemic Emergency Plan (PEP) requirements of Chapter 114 of the Laws of 2020, special focus is required for pandemics.

The Pandemic Emergency Plan requirements include:

  • Pandemic Communication Plan
  • Protection Plans for Staff, Residents and Families
  • Procedures for Sufficient Personal Protective Equipment (PPE) Supplies

Continuing to perform essential functions and provide essential services during a pandemic outbreak is vital to Isabella’s ability to remain a viable entity during times of increased threats. A pandemic outbreak has been identified in the Hazard Vulnerability Analysis (HVA) as a potential emergency/disaster for Isabella Geriatric Center.

Purpose: This plan provides guidance to the facility and may serve as the plan for maintaining essential functions and services during a pandemic. This guidance neither replaces nor supersedes any current, approved Isabella Center for Rehabilitation and Nursing Care continuity plan, but instead supplements it, bridging the gap between all-hazards continuity planning and the specialized planning that may be necessary to appropriately manage a pandemic outbreak in a unique healthcare setting such as a nursing home.

This guidance stresses that essential functions can be maintained during a pandemic outbreak through appropriate mitigations strategies, including:

  • Social distancing
  • Appropriate Infection Prevention & Control protocols
  • Increased hand hygiene
  • Temporary suspension of non-essential activities
  • Temporary suspension of communal activities, such as dining or activities
  • Temporary suspension of in-person visitation from members of the community
  • Appropriate inventory management and use of Personal Protective Equipment (PPE)

Planning Assumptions: Isabella’s pandemic plan is based on assumptions included in the Federal Office of Emergency Management (FEMA) National Strategy for Influenza Implementation Assumptions as well as lessons learned from the COVID-19 pandemic. These include:

  • Susceptibility to pandemic viruses will be universal, but also elevated in congregate nursing facilities due to the resident population
  • Efficient and sustained person-to-person transmission serves as a signal of an imminent pandemic
  • Rates of absenteeism will depend on the severity of the pandemic. A pandemic outbreak threatens Isabella’s human resources by potentially removing essential personnel from the workplace for extended periods of time. Public health measures such as quarantining household contacts of infected individuals or mandatory self-quarantine for workers potentially exposed to a virus may increase absenteeism.
  • Multiple waves/periods during which outbreaks occur in a community can be expected, as is historically seen with influenza.
  • Appropriate guidance and/or direction will be provided by federal, state and/or local governments regarding current pandemic status in the community where Isabella Geriatric Center is located.

Infectious Disease Preparedness, Response and Recovery

 Infectious Disease Preparedness Planning

As part of its preparedness planning for any infectious disease event, the facility takes the following steps:

  • Educates staff on infectious diseases, including any reporting requirements, exposure risks, symptoms, prevention, infection control, proper use of PPE, and any related regulations, guidance or directives.
  • As part of its overall emergency/disaster preparedness planning, Isabella ensures that all employees receive specific training on their individual, departmental and facility-wide roles during any emergency/disaster at the time of orientation, and at least annual thereafter, with an increasing frequency as needed.
  • Reviews and revises, if necessary, existing Infection Prevention and Control policies, including mandatory reporting. Policy updates are reviewed by the Department Heads as appropriate and disseminated to all employees based on their role/department. Inservice training and competencies are conducted to enforce compliance with procedures.
  • As new guidance arises from the Centers for Disease Control (CDC), NYSDOH or other regulatory body, new policies or practices will be developed and implemented consistent with these best practices.
  • The Infection Preventionist conducts routine, ongoing infectious disease surveillance to adequately identify background rates of infectious diseases and detect significant increases above baseline rates, appropriate action will be taken. Refer to Appendix A – Surveillance, Recording and Reporting of Infection Policy
  • Reviews the plan for testing staff and reviews the emergency staffing plan should the need arise to have staff out of work for periods of time while under observation or quarantine. When directed to do so, and testing capabilities are available for the specific infectious disease concerned, staff are tested per current regulatory requirements. Refer to Appendix B – Advance Preparations – Staff Management
  • Ensures that adequate facility staff members have access to and have been trained for use of communicable disease reporting tools and other outbreak-specific reporting tools, including the Nosocomial Outbreak Reporting Application (NORA), the Health Commerce System (HCS) and HERDS.
  • Reviews and revises, if needed, facility policies and procedures for inventory management of items such as environmental cleaning agents, specific PPE, and medications.
  • Develops and implements administrative controls, including visitation policies, employee absenteeism plans and staff wellness/symptom monitoring.
  • Reviews and revises procedures for environmental controls as necessary and based upon best practices for infection prevention and control.
  • Reviews and revises, as necessary, vendor supply plans to ensure adequate supplies of food, water, medications, sanitizing agents and other supplies are available. Refer to Isabella Emergency Operations Plan.
  • Develops, reviews, or revises the facility’s plan to ensure that residents are isolated/ cohorted and/or transferred based on their infection status in accordance with applicable NYSDOH and Centers for Disease Control and Prevention (CDC) guidance. Facility cohorting plans include using distinct areas within the facility, depending on the type of outbreak and cohorting required. Any sharing of bathroom facilities with residents outside of the cohort is discontinued.
  • Reviews and revises, as necessary, the facility’s plan to ensure social distancing measures can be put into place where indicated and required.
  • The facility has plans in place to effectively suspend all non-essential activities, communal dining and activities/ programs, and if required, suspend outside visitation (with the exception of compassionate care situations, if allowable).
  • In accordance with State, NYSDOH, and CDC guidance at the time of a specific infectious disease outbreak or pandemic event, the facility will develop and implement a plan to recover/return to normal operations as specified in regulatory guidance. Updates will be made in accordance with changes to recommendations and requirements. If approval by the State is required, such as in the case of COVID-19 Visitation Plans, plans will be developed and submitted timely. The administrator or designee will be responsible for transmitting these plans.

Infectious Disease Response Tasks 

  • During an infectious disease outbreak, the facility will implement procedures to ensure that current guidance and advisories from NYSDOH and CDC on disease-specific response actions are obtained and followed.
    • Education will be provided to all staff consistent with their roles.
    • Public Relations/designee will send an email message and update the facility’s public website to provide pertinent information to authorized family members and guardians.
    • Residents will be provided with relevant information and the protections that the facility is putting into place for their safety through one of the following processes: Resident council meetings, communication letters, 1:1 communications via interdisciplinary team and close-circuit television.
  • Current signage will be obtained and posted throughout the facility. The Infection Preventionist will ensure signage for cough etiquette, hand washing, and other hygiene measures are posted in high visibility areas. Environmental Services will ensure hand sanitizer is available throughout the facility, as well as other source control supplies if practical and warranted.
  • The Infection Preventionist will ensure that the facility meets all reporting requirements for suspected or confirmed communicable diseases as mandated by New York State. Refer to Appendix A.
  • The Administrator or designee will ensure that the facility meets all reporting requirements of the Health Commerce System, e.g. HERDS survey reporting within required timeframes.
  • In order to limit exposure between infected and non-infected residents, the facility will develop and implement a plan, in accordance with any applicable NYSDOH and CDC guidance and facility Infection Prevention and Control Policies and Procedures, to segregate impacted residents.
  • If the need to develop cohorts arises, the facility will implement procedures to ensure that as much as possible, staff are separated and do not provide care outside of a specific cohort.
  • In response to the infectious disease outbreak, the facility will conduct cleaning/ decontamination in accordance with any applicable NYSDOH, CDC and Environmental Protection Agency (EPA) guidance and facility policy for cleansing and disinfection of isolation rooms.
  • The facility will provide education to residents, family members and other related parties about the disease and the facility’s response strategy at a level appropriate to their need for information and interest level. This education will be provided during family meetings, care plan meetings, resident council meetings or via website or mailings and when residents are advised about the potential viral threat.
  • All staff, vendors and relevant stakeholders will be contacted and provided with information on the facility’s policies and procedures related to minimizing exposure risks to residents, such as by limiting the types of staff, contract staff or vendors who may enter the premises, resident care areas or other changes from normal operations.
  • Social Services or designee will advise family members that their visits should be limited to reduce exposure risk to residents and staff, subject to any superseding New York State Executive Orders and/or NYSDOH guidance that may otherwise temporarily prohibit visitors. Signage will be placed on all entrance doors alerting visitors. The executive team will be responsible for implementing any necessary screening procedures for visitation.
  • If necessary, and in accordance with applicable New York State Executive Orders and/or NYSDOH guidance, the facility will implement procedures to close the facility to new admissions, implement limits to visitors when there are confirmed cases in the community, and/or screen all permitted visitors for signs of infection. Screeners or designees will be responsible for screening all visitors.
  • All staff will be provided with re-education on the appropriate use of PPE, including donning and doffing and utilizing the appropriate PPE. Competencies will be conducted, and supervisors will monitor for compliance. Immediate re-education will occur if non-compliant practice is identified.

Infectious Disease Event Recovery Activities

  • The facility will maintain, review and implement procedures provided in NYSDOH and CDC recovery guidance that is issued at the time of a specific infectious disease outbreak or pandemic event, regarding:
    • How, when and which activities/ procedures/ restrictions may be eliminated
    • How, when and which activities/ procedures/ restrictions may be restored
    • The timing of when specific changes may be executed
  • The facility will communicate any relevant activities regarding the recovery process or return to normal operations to staff, authorized families and guardians, residents and other relevant stakeholders.

Pandemic Management Approach

Isabella’s approach to managing a pandemic, including its plan for managing resident and staff safety and communications with interested parties, will be determined by the level of spread of the associated virus, such as COVID-19, in the surrounding community. The priority of Isabella Center for Rehabilitation and Nursing Care is to maintain a safe and healthy workplace and minimize the transmission of a virus to residents and staff. Isabella will ensure that all federal, state and local directives and guidance are appropriately followed during a pandemic event.

Section 1 – Pandemic Communication Plan

The Pandemic Communication Plan follows the overall Isabella Center for Rehabilitation and Nursing Care Corporate Emergency Operations Plan (EOP) and includes the required elements for notifications needed in the Pandemic Emergency Plan (PEP).

The Isabella Emergency Operations Committee is responsible for oversight, has developed this specific Communication Plan based on regulatory requirements and lessons learned from the COVID-19 pandemic.

Included in the Plan are the following elements, required in the PEP:

  • Plan for ensuring all residents have daily access, at no cost, to remote videoconference or equivalent communication methods with family members and guardians
  • Plan to update authorized family members of guardians of infected residents at least once per day and upon a change in a resident’s condition
  • Plan to update authorized family members of guardians on the number of infections and deaths at the facility, by electronic or such means as may be selected by each authorized family member or guardian

Procedure for Keeping Residents and Families in Communication

In accordance with PEP requirements and NYSDOH guideline C20-01, the facility will implement the following mechanisms to provide all residents with no-cost daily access to remote video conference or equivalent communication methods with family members/guardians.

  • Face-to-face video calls
  • Phone calls

All residents will be offered assistance in making phone calls and/or video conferencing with family members. Assistance with these calls will be documented in the resident’s record. If a resident is unable to communicate via telephone, the family will be kept apprised of their status by the interdisciplinary team.

Communication Procedures Based on Threat Level

Communication When There are No Cases in New York and No Impact to Staff and Patients

When there is growing concern about a pandemic outbreak, but there are currently no New York State or New York City cases, and there is no impact on staff and patients, the facility will ensure that frequent updates are made to residents, family members, staff and internal stakeholders.

  • A record of all authorized family members and guardians, including a secondary/backup authorized contact (as applicable) is maintained in the Electronic Medical Record. A list of family contacts to be used in the Communications Plan will be developed by the Admissions team and submitted to the interdisciplinary team for Emergency Communication Purposes.
  • Social Services will determine, if not already known, what the preferred method used for updates of the authorized family member(s) or guardian is during a pandemic outbreak, in accordance with the requirements of the PEP regulation.

In these circumstances:

  • Updates are made one time per week, as there is no impact to staff or residents in these circumstances.
  • Updates are sent out by Public Relations via the following means:
    • Email
    • Text Message
    • Traditional mail
    • Website
  • The facility will educate the families so they know what measures are being taken and why. Information regarding the pandemic illness, including information about signs and symptoms, will be provided to residents, staff members and families by the interdisciplinary team as appropriate.
  • Residents will be provided with updates weekly and as needed via the interdisciplinary team so they know what measures are being taken for their safety and why.

Communication When There Are Cases in New York/ New York City with No Impact to Staff or Patients

When there are cases in New York State and/or New York City, with no impact on staff or patients, communication frequency will be increased.

  • Internal Communications will include: verbal and written communication as appropriate
  • External Communications will include: website updates, emails, letters, text messages and recorded phone messages.
  • Authorized family members will be kept notified via email alerts, Isabella public website updates, text messages and other means which will be updated per regulatory requirements for updates.

Communication When There Are Cases within the Facility or Staff are Impacted

When there are positive cases at Isabella, or our staff members have been impacted, Isabella will provide consistent communications with staff, residents and family members. Per the regulatory requirements for PEP, each authorized contact will be communicated within the manner he/she prefers.

Pandemic Response Plan-Specific Notification Procedures

Procedure for When a Resident is Infected

In accordance with PEP requirements, the facility will utilize the following methods to update authorized family members and guardians of infected residents (i.e.) those infected with a pandemic-related infection) at least once per day and upon a change in a resident’s condition:

  • Nursing/Medical will call each family member/guardian to provide an update once per day and upon a change in condition.

Procedure for Weekly Updates on Facility Status

In accordance with PEP requirements, the facility will implement the following procedures/methods to ensure that all residents and authorized family members/guardians are updated at least once per week on the number of pandemic-related infections and deaths at the facility, including residents with a pandemic-related infection who pass away for reasons other than such infection:

  • Isabella facilities use multiple methods to notify all residents in the facility, their representatives and families regarding the status of the facility and its residents, not just those who are suspected/confirmed cases (per CMS QSO Memo QSO-20-29-NH and DAL NH 20-09).
  • Notification will include all regulatorily-required information, such as through notification requirements when confirmed or suspected cases have been identified.
  • All required reporting timeframes will be adhered to, with updates provided at a minimum of 1x per week for general facility status updates.
  • Communications will be respectful of privacy laws, considering HIPAA-compliant protocols and protecting PHI.
  • The facility will make all reasonable efforts to properly inform their residents, representatives and families of the information required, including through means authorized representatives have selected as preferred, including:
    • Isabella facility website posting/updates
    • Email list servs
    • Recorded telephone messages
    • Mailings

Posting of Facility Pandemic Emergency Plan

In accordance with PEP requirements, the facility will follow procedures to post a copy of the facility’s PEP, in an acceptable form to the Commissioner and on the facility’s public website. The PEP will also be available immediately upon request.

  • To the Commissioner
    • The finalized PEP will be sent to NYSDOH as required on or before September 15, 2020.
    • The administrator or designee will be responsible for transmitting this plan.
  • On the facility’s public website
    • The finalized PEP will be provided in .pdf format for viewing on the facility’s public website at the same time that it is transmitted to NYSDOH.
    • Public Relations is responsible for uploading the plan to the website.

Section 2 – Protection of Staff, Residents and Families Against Infection

The facility’s Pandemic Emergency Plan includes:

  • Plans to protect staff, residents and families through enhanced screening processes, changes to staffing, and the use of designated units for cohorting residents of similar status
  • A plan for hospitalized residents to be readmitted to the facility after treatment, in accordance with all applicable laws and regulations
  • A plan to preserve a resident’s place in the facility if such resident is hospitalized, in accordance with all applicable laws and regulations
  • A plan for the facility to maintain or contract to have at least a two-month (60 day) supply of Personal Protective Equipment (PPE)

Procedures for Protecting Staff, Residents and Families against Infection


  • The facility will monitor all entrances and screen those entering per the facility’s Pandemic Screening policy, including staff, visitors and vendors. Screening types and questions will be based on regulatory guidance, including, but not limited to, CDC, CMS and NYSDOH.
  • All staff will be screened prior to entering the facility and at least every 12 hours. This includes a questionnaire regarding the presence of symptoms, exposure to the virus, and a temperature check. Consistent with the guidance set out during the COVID-19 pandemic, any staff with symptoms or a temperature of 100.0 will be sent home with a mask and instructed to call Employee Health.
  • If required by the Centers for Disease Control (CDC) or federal, state or local authorities, all employees, vendors or visitors who have travelled within the time period set out by the authorities to impacted countries/states/locations will be screened and directed to follow appropriate guidelines.
  • Staff who have been potentially exposed to someone with a confirmed case of the virus, or to someone who is a person under investigation (PUI), will be placed under precautionary quarantine or mandatory quarantine by public health officials, based on the symptoms presented and/or level of risk for having contracted the virus as per current guidelines.
  • All residents must be screened daily for signs and symptoms of the virus, including a temperature check, observing for signs and symptoms consistent with the virus, including symptoms or complaints of cough, shortness of breath, sore throat, elevated temperature, nausea and vomiting or any changes in status. If the resident is on a unit that has residents who are positive, temperatures will be taken each shift.
  • Anyone entering the facility will be reminded of the need to perform appropriate hand hygiene, socially distance and wear a facemask for the duration of their time in the facility, consistent with applicable regulatory recommendations and requirements.


Visitors to the nursing home may introduce the infection into the nursing home if they are ill as a result of community transmission either internationally or in the United States or have had close contact with a person(s) known to have or reasonable suspected to have the virus.

  • The nursing home will have staff available to screen visitors for symptoms or potential exposure to someone with the virus.
  • Post signs at the entrance instructing visitors not to visit if they have symptoms of the pandemic illness. Individuals (regardless of illness presence) who have a known exposure to someone with a confirmed case or who have recently traveled to areas with virus transmission should not enter the nursing home.
  • Visitors who enter the facility will be reminded of the importance of practicing appropriate hand hygiene, social distancing and be required to wear a facemask for their safety. Anyone who is not able to follow these infection control measures will not be permitted to enter the facility.
  • Depending on the level of spread and presence in the community and/or facility, family members may be restricted from visitation if mandated by NYSDOH or other agency for their protection.
    • Any visitation for compassionate care situations, including end of life, must be screened.
    • When visitation is allowed or the facility is reopened to visitors under certain circumstances, the Isabella Visitation Policy will be updated to reflect current guidelines.


Isabella has planned for potential staffing issues during a pandemic, including accounting for increasing levels of absenteeism due to illness or presence of signs or symptoms of the virus, and the need to augment existing staff with outside resources. The following measures provide an overview of the measures that will be taken:

  • Reinforce sick leave policies. Ask employees to stay home if they have symptoms of the pandemic illness/flu or are ill. They should call rather than coming in for medical advice. Management should monitor sick calls for compliance. If they notice an employee exhibiting signs of infection, they should send that person home.
  • As much as possible, in-person meetings will be avoided, and the use of conference calls and other electronic methods will be implemented.
  • Staff who have symptoms of the pandemic illness will be excluded from work and referred to eMployee Health for clearance to return to work.
  • Human Resources will implement its plan to augment staffing through outside agency staff. If necessary, the NYC Office of Emergency Management and New York State Department of Health, among other agencies, will be contacted for assistance with emergency staffing resources.

Infection Control and Cohorting

Infection Control during a Pandemic

  • Any residents suspected of having symptoms of the Pandemic illness will immediately be placed on Contact and Droplet precautions. Staff will notify their supervisior and communicate with the infection control practitioner.
  • Symptomatic residents will be given a mask to wear, if tolerated, when out of their rooms.
  • Residents with suspected or confirmed infections should be given a surgical or procedure mask to wear, if tolerated, during care and maintained on Contact and Droplet precautions.
  • All residents will be encouraged to stay in their rooms at all times. For residents who cannot remain in their rooms, staff will encourage and reinforce social distancing.
  • For a cluster of symptomatic residents, a line list will be created and a NORA report will be submitted to NYSDOH.
  • Staff shall utilize Standard, Enhanced Contact and Droplet precautions (including a N95 mask + eye protection which includes surgical mask with either goggles or face shield, a gown and gloves) when handling any resident suspected to have or who has the Pandemic illness. If N95 masks are not available or in short supply, a surgical mask is sufficient except during aerosolizing procedures.
  • Standard, Enhanced Contact and Droplet precautions (N95 masks + eye protection) are required when providing care for suspected ot positive patients that may result in aerosolizing droplets (e.g. during procedures and when ventilated)
  • In the event that a resident requires hospitalization, the resident must be isolated in a separate room with the door closed and transported with a mask. Ambulance transport and the receiving hospital must be notified that a resident is a confirmed positive case or a person under investigation due to possible exposure.


  • Signage will be posted on the door or wall outside of the resident room or confirmed positive wing that clearly describe the type of precautions needed and/or required PPE.
  • Ensure proper signage is in place to demarcate that this is a restricted area to prevent residents from entering unknowingly and to ensure staff are reminded of the need for precautions.
  • Separate staffing teams will care for positive residents, suspected residents and non-positive residents.
  • During an outbreak, the interdisciplinary team will evaluate and cohort positive, negative, unknown (including inconclusive/invalid test results) and not testing cases in the designated units.
  • All positive cases will be isolated on a designated positive unit. This unit may be either a full unit or designated part of a unit dependent on the number of residents impacted.
  • All new suspected cases will be tested for the virus, isolated and moved to the unit designated for suspected cases. If the test result is positive, the resident will be moved to the positive unit. If the test result is negative, the resident will be moved back to the original room in the non-positive until provided NYSDOH non-test-based strategy or test-based strategy guidelines for discontinuing C/D isolation are met as follows:
    • Non-test-based strategy:
      • At least 72 hours of being asymptomatic (lack of fever off anti-pyretic) and improvement in symptoms AND
      • At least 14 days have passed since symptoms attributed to virus first appeared
    • Test-based strategy:
      • Lack of fever (greater than or equal to 100.0F) without anti-pyretic and improvement in symptoms AND
      • Two virus molecular assay test results negative performed at least 24 hours apart
    • If a new suspected case has an asymptomatic roommate, the roommate will be considered as possible exposure and will be tested and isolated in the same room until the test results become available. If the result is positive, the resident will be moved to the positive unit. If the result is negative and the patient remains asymptomic, then the resident will continue to remain in the same room.
    • All unknown, not testing and inconclusive/invalid cases will be isolated in the designated units.
    • All test-negative and recovered cases will be placed in non-positive units.

Admissions, Readmissions and Bed Hold/ Bed Reservation

The facility’s PEP considers that hospitalized residents may need to be readmitted to the facility after treatment. The plan also considers that a plan should be in place for preserving a resident’s place in the facility if that resident is hospitalized.

The facility has developed and put into place a thorough plan with these considerations in mind, with the overall goal of protecting all residents and staff. This includes planning for protecting residents who remain in the facility, are readmitted to the facility or are new admissions from the hospital, consistent with New York State and NYSDOH directives and all regulatory requirements. This includes implementation of dedicated units/wings for residents of differing pandemic-related health status and drives the decisions for where a resident will reside upon readmission or admission from the hospital.

New Admissions to the Facility

Should it be necessary to accept pandemic virus positive patients from hospitals, the NYSDOH guidance provided during COVID-19 will serve as the basis for admitting new patients in the absence of more current guidance.

  • Security will notify the nursing supervisor when an admission arrives. If the status of the admission is unknown, the new admission will be screened prior to bringing the resident to the unit. If the admission has any signs and smyptoms of an elevated temperature or respiratory symptoms, a mask will be placed on the resident and the physician will be contacted for further evaluation, including admitting diagnosis and history of exposure.
  • All positive cases will be admitted to the facility in the a designated positive unit.
  • Alll admissions recovered from the virus and not requiring isolation must meet qualifying facility criteria for discontinuing isolation.
  • Patients with previously confirmed cases will be admitted with a minimum of one negative result to a private room or cohorted with another patient pending of the same status in the designated unit until a second result is received in the designated unit.
  • All non-virus admissions will be admitted to the non-virus unit.

Accepting Patients from Hospitals

NYSDOH Guidance for accepting patients from hospitals during the COVID-19 pandemic will be followed in the absence of more current guidance. Per NYSDOH Guidance:

  • “Separate residents into cohorts of positive, negative, and unknown as well as separate staffing teams to deal with COVID-19 positive residents and non-positive residents. In order to effectuate this policy, nursing home facilities should transfer residents within a facility, to another long-term care facility, or to another non-certified location if they are unable to successful separate out patients in individual facilities.
  • If your facility is unable to meet cohorting standards or any infection control standards, admission must be suspended to the facility. Failure to adhere to these standards will result in civil monetary penalties and/or revocation of your license.”

Bed Hold, Return to Facility & Readmission of Hospitalized Residents

Per the requirements of the PEP regulation, Isabella will follow its Bed Reservation/ Bed Hold Policy to preserve a resident’s place in the facility if such a resident is hospitalized, in accordance with applicable laws and regulations, including, but not limited to: 18 NYCRR 505.9(d)(6) and 42 CFR 483.15(e). The facility will also follow this process to assure hospitalized residents will be admitted or readmitted to the facility 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 415.26(i); and 42 CFR 483.15(e). Refer to Appendix C – Bed Reservation/ Bed Hold Policy

Section 3 – Procedures for Sufficient PPE Supplies

Per the PEP requirements, the facility will develop pandemic infection control plans for staff, residents and families. This includes:

  • Developing supply stores and specific plans to maintain, or contract to maintain, at least a two-month (60 day) supply of personal protective equipment (PPE) based on facility census, including consideration of space for storage.

Personal Protective Equipment Supply

In accordance with PEP requirements, the facility will implement the following planned procedures to maintain or contract to have at least a two-month (60-day) supply of personal protective equipment (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 during a specific disease outbreak or pandemic. As a minimum, all types of PPE found to be necessary in the COVID-19 pandemic should be included in the 60-day stockpile. This includes, but is not limited to:

  • N95 respirators
  • Face shields
  • Eye protection
  • Gowns/Isolation Gowns
  • Gloves
  • Masks
  • Sanitizer
  • Disinfectants (meeting EPA Guidance current at the time of the pandemic)

A 60-day supply of necessary PPE will be maintained at the nursing home or designated easily accessible location.

The facility will maintain a plan for identifying what quantities of PPE will be required for 60 days, calculated based on the peak COVID-19 week of April 19, 2020 – April 27, 2020.


Appendix A – Surveillance, Recording and Reporting of Infection Policy


EFFECTIVE: February 2018 SUPERCEDES: June 2018

PURPOSE:     1. To outline a systematic approach of data collection, comparison, analysis and dissemination of infection events and rates.

  1. To promote patient safety by identifying areas for improvement that supports and minimizes infection rates.
  2. To monitor changes in infection rates and maximize control measures to minimize the impact of epidemics or outbreaks.
  3. Identification of patients at risk for Health Care Associated Infections (HAI) and implement prospective Infection Control intervention.

DEFINITION: The continuous and systematic process of collection, analysis, interpretation and dissemination of descriptive information for monitoring health problems, planning, implementation, and evaluation of health care related practices.

HAI: Localized or systemic conditions resulting from an adverse reaction to the presence of an infectious agent not present at the time of admission to the healthcare facility.

INFORMATION: Surveillance includes:

  • Review of practices related to resident care, i.e. hand washing, clean techniques, PPE use, cleaning or disinfecting reusable equipment.
  • Collection, documentation, monitoring, analysis of data on individual cases and comparing to standard definitions of infection.

Infections are tracked to determine the following:

  • Which conditions might be communicable
  • Which are reportable to local and state regulatory agencies
  • Which are nosocomial
  • Which residents require isolation or other precautions
  • Causative agents, control spread and identify prevalence

Accurate records of infections are maintained and made available.

Refer to Policy for Procedure.

Appendix B – Administrative Control Plans

Advance Preparations – Staff Management

Isabella Geriatric Center has proactively planned for potential staffing issues during a pandemic. The strategy for staff management involves many considerations and contingencies that may arise in the event of staffing issues. Advance preparations for staff management include:

  • Prepare staff scheduling enhancements to cover the period, including shift alterations, extended shifts and additional contracted coverage
  • Place off-duty/on-call staff in alert status
  • Review Human Resource policies covering staff absenteeism during emergencies
  • Implement denial of leave requests, cancellation of pre-scheduled leaves and days off and medical clearance for use of sick leave
  • Ensure continuity of executive leadership coverage in the staffing plan
  • Update lists of employees who live in or will stay within close proximity to the facility. Ensure that complete address information, including apartment numbers and contact information, including cell phone, email and text messaging addresses are updated.
  • Facilitate and encourage the establishment of employee self-help transportation pools. Restrict use of facility vehicles to provide staff transportation for extreme circumstances.
  • Create sleeping arrangements or reserve hotel accommodations for key staff
  • Assist staff in preparing their homes and families for the potential event impact (e.g. stocking food, fueling vehicles, reviewing dependent care, family communications plan, personal finance and pet care arrangements)
  • Identify potential need for staff dependent care, including pets, and activate plans as needed
  • Direct incoming personnel to bring extra clothing, food, water and personal necessities, including medications, in preparation for an extended stay
  • Review facility emergency procedures with staff, including shelter in place and evacuation plans, as well as absenteeism policies
  • Brief the Critical Incident Stress Debriefing team, if needed

Appendix C – Bed Reservation/Bed Hold Policy

POLICY:  Bed Reservation/ Bed Hold

EFFECTIVE: September 2020                       SUPERCEDES: April 2017

PURPOSE: To outline the Bed Hold Process when residents are temporarily hospitalized or out of the facility on “therapeutic” days.


  • At the time of admission and again at the time of transfer to hospital, the Resident and/or the Resident’s Designated Representative will be informed orally and in writing off this policy.
  • As of May 29th, 2019, Bed reservation (bed hold) reimbursement will apply as follows:
    • Patients 21 and over on hospice are eligible for 50% of the Medicaid rate otherwise payable to the facility for services provided. Payments cannot exceed 14 days in any 12-month period.
    • Patients 21 and over on therapeutic leaves of absences will be reimbursed at 95% of the Medicaid rate otherwise payable to the facility for services provided. Payments for Therapeutic Leave cannot exceed 10 days in any 12-month period.
    • Patients under 21 will be reimbursed at 100% of the Medicaid rate for hospital, therapeutic and hospice leaves of absences. There are no limits for patients under 21 years old.
  • Medicare does not pay for a bed to be held during hospitalizations or therapeutic leave. Patients whose stay is paid for by Medicare and who wish to have their bed “held” must pay for overnight absences at the prevailing per diem rate.
  • Private paying residents who which to have their bed “held” must pay for overnight absences at the prevailing per diem rate.
  • Health Maintenance Organizations (HMOs) and Managed Long-Term Care Companies (MLTCs) must be notified of and approve a hospital transfer or therapeutic leave and may reimburse the facility.
  • Family members or designated representatives of a Medicaid recipient may pay privately to reserve the Resident’s bed for any days beyond the period of allowable Medicaid reimbursement by paying the facility its daily Medicaid rate for each additional bed hold day requested.
  • If the Resident’s hospitalization or therapeutic leave do not meet the criteria noted here, the facility will re-admit the Resident to his or her previous room, if available, or immediately upon the first availability of a bed in a semi-private room, provided the Resident:
    • Requires the services provided by the facility; and
    • Is eligible for Medicare skilled nursing services or Medicaid nursing home services.
  • At the time of transfer to the hospital or commencement of therapeutic leave, the Resident and/or Resident’s Designated Representative will be provided with the following information orally and in writing:
    • The bed-hold policy for hospitalization or therapeutic leave, as applicable;
    • Reasons the Resident is being transferred to the hospital;
    • The effective date of the transfer or leave;
    • The location to which the Resident is transferred or will be staying on therapeutic leave.
  • The Resident or Resident’s Designated Representative will be provided with instructions on how to appeal the transfer to the hospital.
  • If the facility determines that a Resident who was transferred with an expectation of returning to the facility cannot return, the facility will provide Resident with the following information, sending a copy to the State Ombudsman:
    • The reason the Resident is being discharged;
    • The effective date of the discharge;
    • The location to which the Resident is discharged;
    • Instructions on how to appeal the discharge.