Monroe Community Hospital

Infectious Disease/Pandemic Emergency Plan

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.

The following Infectious Disease/Pandemic Emergency Checklist outlines the hazard-specific preparedness, response, and recovery activities the facility should plan for that are unique to an incident involving infectious disease as well as those incidents that rise to the occasion of a pandemic emergency.  The facility should indicate for each checklist item, how they plan to address that task.

The Local Health Department (LHD) of each New York State county, maintains prevention agenda priorities compiled from community health assessments. The checklist items noted in this Annex include the identified LHD priorities and focus areas. Monroe Community Hospital uses this information in conjunction with an annual internal risk assessment to create our plan and to set priorities, policies and procedures.

 

Infectious Disease/Pandemic Emergency Checklist

√ Required

Monroe Community Hospital provides education upon hire, and annually on infectious diseases (e.g., reporting requirements, exposure risks, symptoms, prevention, and infection control, correct use of personal protective equipment, regulations, including 10 NYCRR 415.3(i)(3)(iii), 415.19, and 415.26(i); 42 CFR 483.15(e) and 42 CFR § 483.80), and Federal and State  guidance/requirements.

 

√ Required

MCH Infection Preventionist (IP) develops/reviews/revises and enforces existing infection prevention, control and reporting policies.

 

√ Recommended

MCH conducts routine/ongoing, infectious disease surveillance that is adequate to identify background rates of infectious diseases and detect significant increases above those rates. This will allow for immediate identification when rates increase above these usual baseline levels. The IP’s daily activities include:

  • Active surveillance of facility acquired infections and monitoring of labs and EMAR reports. 

  • Completion of tracking tool, by unit, for monitoring. The IP reports communicable diseases to the appropriate agencies, investigates clusters of infection and potential exposures.

  • Institutes appropriate isolation control measures. 

  • Compile information regularly and compare percentages to national benchmarks.

  • Report data at Infection Control Committee meetings, Quality Assurance meetings.

 

√ Recommended

Develop/Review/Revise plan for staff testing and resident laboratory services as applicable or required. MCH currently contracts with URMC for laboratory services and Quest diagnostics for staff testing.

 

√ Required

Review and assure that there is adequate facility staff access to communicable disease reporting tools and other outbreak specific reporting requirements on the Health Commerce System (e.g., Nosocomial Outbreak Reporting Application (NORA), HERDS surveys.  All MCH Administrative staff and the IP are able to report through HCS.

 

√ Required

Develop/Review/Revise internal policies and procedures to ensure adequate stock of medications, environmental cleaning agents, and personal protective equipment as necessary. The facility maintains adequate supplies to assure quality care of residents. The Chief Pharmacist informs the MCH medical director and MCH administration of medication supply issues and orders from a variety of vendors to keep supplies adequate. The EVS Director monitors cleaning agents and hand sanitizer for the facility, and will identify substitute products if there are shortages, assuring products are appropriate for bacterial and viral cleaning benchmarks. Departments work with the Materials Manager to assure adequate supplies based on burn rates.  The Material Manager monitors PPE levels and reports levels regularly (minimum weekly).

 

√ Recommended

Develop/Review/Revise administrative controls (e.g., visitor policies, employee absentee plans, staff wellness/symptoms monitoring, human resource issues for employee leave).

 

√ Required

Develop/Review/Revise environmental controls.  The facility collects contaminated waste in accordance with all State and Federal guidelines.  Red Biohazard containers are available throughout the facility.  They are emptied regularly and the waste is collected and burned per guidelines.

√ Required

Develop/Review/Revise vendor supply plan for re-supply of food, water, medications, other supplies, and sanitizing agents. Director of Food and Nutrition Services maintains 3 day minimum of food items and maintains list of alternate vendors if food supply is affected.

 

√ Required

Develop/Review/Revise facility 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. The IP and Medical staff collaborate to identify infectious processes. The negative pressure room and various private rooms are identified for use in isolating, and semi-privates identified for cohorting residents, per guidelines.  The facility has procedures in place to assess residents and transfer them to a higher level of care if directed by the medical providers.  Procedures for masking are in place if transferring a resident is necessary. MCH has an established plan in place for cohorting, including use of groupings of rooms on the FA5E Rehab unit.  This includes discontinuing any sharing of a bathroom with residents outside the cohort.

 

√ Recommended

Develop/Review/Revise a plan to ensure social distancing measures can be put into place where indicated, including modification or cessation of group activities, communal dining for residents/staff, rehab and group gatherings, events, clinic visits, and visitation. This includes physical modifications to space to ensure social distancing. Provide education on social distancing to residents and staff members.

√ Recommended

Develop/Review/Revise a plan to recover/return to normal operations when, and as specified by, New York State Department of Health 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. Follow appropriate guidance and communicate plan for recovery/return to normal operations with residents, staff and representatives.

Additional Preparedness Planning Tasks for Pandemic Events

 

√ Required

In accordance with PEP requirements, Develop/Review/Revise a Pandemic Communication Plan that includes all required elements of the PEP. County administration, public relations, facility administration and key stakeholders will be involved in planning and communications.

 

√ Required

In accordance with PEP requirements, Develop/Review/Revise plans for protection of staff, residents and families against infection that includes all required elements of the PEP. Federal, state and local regulations will be followed. Facility administration and key stakeholders will be involved in planning for implementation of all regulatory guidance.

Response Tasks for all Infectious Disease Events:

 

√ Recommended

The facility will implement the following procedures to 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, e.g., including management of residents and staff suspected or confirmed to have disease: 
Administrative staff are registered with local and federal agencies and receive regular guidance on regulations as they become available. Participation in educational webinars, community meetings and nursing home association (LeadingAge) meetings, to discuss current guidance as it applies to nursing homes.  Daily meetings to assure compliance with guidance. Appropriate signage is created or obtained for posting in the facility to facilitate compliance.

 

√ Required

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.  The IP has a list of all reportable communicable diseases.  This list is referred to when reporting into the NYS system. The IP or Facility Administrators report all required CDC reports for the current pandemic.  Multiple facility personal have access to HCS and NHSN to assure reporting availability.

 

√ Required

The facility will assure it meets all reporting requirements of the Health Commerce System, e.g. HERDS survey reporting, NHSN reporting. Access and training for individuals responsible for reporting will be completed.

 

√ Required

The IP will clearly post signs for cough etiquette, hand washing, and other hygiene measures in high visibility areas. Provide hand sanitizer, face/nose masks, and other PPE as appropriate.

 

√ Recommended

MCH will implement the following procedures to limit exposure between infected and non-infected persons and consider segregation of ill persons, in accordance with any applicable NYSDOH and CDC guidance, as well as with facility infection control and prevention program policies. 

 

√ Recommended

MCH will implement the following procedures to ensure that as much as is possible, separate staffing is provided to care for each infection status cohort, including surge staffing strategies: 

  • MCH will utilize groups of rooms on the Faith 5 East Rehab unit to cohort infected patients if a cluster should occur.  The area would be staffed accordingly with those individuals dedicated to the cohort.

  • Identify non nursing personnel that may be trained to assist with nonclinical tasks.

  • Engage county administration to determine if hazard/crisis pay can be instituted for staff.

 

√ Recommended

MCH will conduct cleaning/decontamination in response to the infectious disease in accordance with any applicable NYSDOH, EPA and CDC guidance, as well as with facility policy for cleaning and disinfecting of isolation rooms. 

 

√ Required

MCH will develop policies and implement procedures to provide residents, relatives, and friends with education about the disease and the facility’s response strategy at a level appropriate to their interests and need for information.

 

√ Recommended

MCH will contact all staff, vendors, other relevant stakeholders on the facility’s policies and procedures related to minimizing exposure risks to residents. Vendor and contractor contact information is stored on ContrackHQ.

 

√ Required

Subject to any superseding New York State Executive Orders and/or NYSDOH guidance that may otherwise temporarily prohibit visitors, the facility will advise visitors to limit visits to reduce exposure risk to residents and staff.

If necessary, and in accordance with applicable New York State Executive Orders and/or NYSDOH guidance, the facility will close/restrict new admissions and/or restrict visitors when there are confirmed cases in the community and/or to screen all permitted visitors for signs of infection.

Additional Response Tasks for Pandemic Events:

 

√ Recommended

Ensure staff are using PPE properly (appropriate fit, don/doff, appropriate choice of PPE per procedures).  The facility has multiple staff who are trained to fit test N-95 respirators as needed.  The facility has all appropriate PPE, in various sizes, available in resident care areas.  Annual training for Donning and Doffing of PPE is required.  In-servicing and audits are completed to monitor.  Policies and procedures for PPE are available on line and copies of these procedures are posted on resident care units.  Check sheets and algorithms are available to the staff to help with correct PPE usage for various clinical scenarios.

 

√ Required

In accordance with PEP requirements, MCH will post a copy of MCH’s PEP.  The PEP will be in a form acceptable to the commissioner, on MCH’s public website, and be made available immediately upon request.

 

√ Required

In accordance with PEP requirements, MCH will utilize Social Work and/or other staff as needed to call and 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.

 

√ Required

In accordance with PEP requirements, MCH will utilize the facility website to communicate standardized updates unless another method is specified by the resident, family member, or representative, to ensure that all parties are updated at least once a 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.   

 

√ Required

In accordance with PEP requirements, MCH will offer residents with no cost, daily access to remote videoconference (Facetime, Zoom, etc.) or equivalent communication methods with family members and guardians.

 

√ Required

In accordance with PEP requirements, MCH will implement the following process/procedures to assure hospitalized residents will be admitted or readmitted to such residential health care facility or alternate care site after treatment, in accordance with all applicable laws and regulations, including but not limited to 10 NYCRR 415.3(i)(3)(iii), 415.19, and 415.26(i); and 42 CFR 483.15(e): All current residents hospitalized with pandemic infection or potential admissions who are receiving treatment will be reviewed at daily bed/admission meeting so that the facility can plan for readmission/admission.

 

√ Required

In accordance with PEP requirements, MCH will implement the following process 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): The admitting department will review and track residents who have been sent to the hospital and/or admitted. They will monitor the resident(s) hospitalization and coordinate with the hospital to re-admit the resident to an appropriate bed in the facility.

 

√ Required

In accordance with PEP requirements, MCH will implement the following planned procedures to maintain at least a two-month (60-day) supply of personal protective equipment (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.  As a minimum, all types of PPE found to be necessary in the COVID pandemic should be included in the 60-day stockpile.


This includes, but is not limited to:

  • N95 respirators

  • Face shield

  • Eye protection

  • Gowns/isolation gowns

  • Gloves

  • Masks 

  • Sanitizer and disinfectants (meeting EPA Guidance current at the time of the pandemic)

MCH will perform regular inventory of personal protective equipment (PPE) (minimum weekly) to identify burn rate, trends, and forecast future needs. MCH participates with a Group Purchasing Organization (Pandion/Premier) in addition to utilizing alternative vendors to obtain required supplies. In the event that procurement of equipment/supplies will be challenged, MCH will contact the Monroe County Emergency Operations Center, local, and state health departments, and/or local nursing facilities in the community to determine if PPE is available.

Recovery for all Infectious Disease Events

 

√ Required

MCH 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.

 

√ Required

MCH will communicate any relevant activities regarding recovery/return to normal operations, with staff, families/guardians and other relevant stakeholders

Monroe Community Hospital

435 East Henrietta Road

Rochester, NY 14620

info@monroehosp.org

Phone: (585) 760-6500

Fax: (585) 760-6066

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