Pandemic Emergency Plan

Chapin Home Pandemic Emergency Plan (PEP)

The Centers for Medicare and Medicaid Services (CMS) requires healthcare facilities to conduct annual facility-specific risk assessments to identify and assess potential hazards and their impacts. HVAs are used to estimate the hazards (and associated risks) that are most likely to occur and/or may affect a facility’s ability to maintain operations and services. The results of the analysis can be used to prioritize planning, mitigation, response, and recovery projects and initiatives.
 
Chapin Home HVA is an assessment conducted of facility-based and community-based risk assessments and pre-disaster collaboration with Chapin Home stakeholders such as Health Emergency Preparedness Coalitions, mutual aid partners, local emergency management agency.
 
The Pandemic Emergency Plan was established to protect the well-being of Chapin Home residents, staff, and visitors, the following all-hazards Comprehensive Emergency Management Plan (CEMP) has been developed and includes considerations necessary to satisfy the requirements for a Pandemic Emergency Plan (PEP).  Appendix E: Infectious Disease/Pandemic Emergency of the CEMP has been adjusted to meet the needs of Chapin Home, the PEP has been updated to include guidance and formatted to  comply with the new requirements of Chapter 114 of the Laws of 2020 for the development of a Pandemic Emergency Plan (PEP). This CEMP is a living document that will be reviewed annually, at a minimum, in accordance with the requirements of Chapter 114 of the Laws of 2020.
 
 
Provide staff education on infectious diseases (e.g., reporting requirements (see Annex K of the CEMP toolkit), 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.
Chapin Home continues to provide education and training to all staff on basic infection prevention and control measures, including recognizing exposure risk and utilizing personal protective equipment (PPE) correctly, reporting requirements and regulations.
–       The In-Service Coordinator has been designated in collaboration with the Infection Control Nurse (ICN) for coordinating education and training on the Infectious Disease/Pandemic Plan.
–       All staff is provided Infection Control and Prevention training upon hire, annually and on ongoing bases as determined by the need of the facility.
–       All staff during the year will receive various infection control in-services as determine by the facility via in-person, online (Healthcare Academy),
        education materials and demonstration.
–       Chapin Home maintains an expedited process for education and training of staff hired during a pandemic event.
–       Informational infection control materials on pandemic related illness and relevant policies will be available for residents and their families.
        Materials will be posted in the facility, on facility web site, included during mailing notifications.
–       All staff will receive education annually on reporting any change in resident condition to supervisor and/or designated physician.
–       All staff received education and training related to cohorting of resident into 3 groups; Unknown, Negative and Positive as it relates to the infectious
​        agent.
 
► Please refer to Policy Infectious Disease Threat Training and Education
► Please refer to Policy Pandemic Infection Suspected or Confirmed
 
Develop/Review/Revise and Enforce existing infection prevention, control, and reporting policies. Chapin Home continue to review, revise and update policies and procedure annual and as needed.
–       The Infection Control Policy and Procedure manual is reviewed and revised by the Director of Nursing, Infection Control Nurse, Medical Director and Administrator annually.
–       The facility will continue to review/revise as well as enforce existing infection prevention control and reporting policies.
–       The update/revised Infection Control manual, is available to the staff digital and in print format, annually or as required during a pandemic event.
–       Chapin Home infection control policy requires all direct care staff to use Categories of Transmission – Based Precautions when in close contact with symptomatic residents is in place.
 
            ► Please refer to Policy Reporting Communicable Disease
            ► Please refer to Policy Isolation Categories of Transmission – Based Precautions
 
Conduct 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.
–       ICN has the assigned responsibility for monitoring public health advisories and updating the Administration and the pandemic planning committee when a pandemic illness has been reported in the United States and its nearing the geographic area.
–       The ICN will be utilized for infectious disease threat information and planning:
1.     The Center for Disease Control and Prevention (CDC)
2.     Center for Medicare and Medicaid Services (CMS)
3.     New York State Department of Health (NYSDOH)
4.     New York City Department of Health (NYCDOH)
5.     State and local emergency preparedness groups
6.     State long-term care professional/trade associations
7.     Local area hospital
–       Evaluation and diagnosis of residents and/or staff with symptoms will follow the CDC guidelines for evaluation of symptoms and laboratory diagnostic procedures.
–       Infectious disease surveillance and documentation will be completed to identify and detect increases above the established baseline infection rate. The findings will be reported at the Quality Assurance Performance Improvement (QAPI) Committee meeting to identify trends and any area for improvement.
 
► Please refer to Policy Infectious Disease Threat Surveillance and Detection
► Please refer to Policy Infectious Disease Threat Pandemic, Infection Control Measures
► Please refer to Policy Infectious Disease Threat Communication
 
Develop/Review/Revise plan for staff testing/laboratory services.
–       Chapin Home will conduct staff testing, as indicated, in accordance with NYS DOH and CDC recommendations for infectious/ pandemic.
–       Chapin Home will acquire and maintain arrangements with laboratory services to accommodate any testing of residents, staff, including contract employees and required service vendors.
–       Administrator, Human Resource and ICN will ensure ongoing surveillance to ensure compliance with staff and resident testing and results.
–       Chapin Home has developed a policy based on regulation for reporting to NYSDOH
 
► Please refer to Policy Employee COVID Testing
► Please refer to Policy Reporting Communicable Disease
 
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,
–       The facility will ensure designated staff receives training and enrollment on the Health Commerce System (HCS).
–       The facility has developed a policy based on regulation for reporting to NYSDOH.
–       The facility has implemented procedure to ensure, which includes adequate staff to access reporting tools on communicable disease via the Health Commerce System (HCS), National Healthcare Safety Network (NSHN) weekly report and Health Emergency Response Data System (HERDS) daily report.
 
► Please refer to Policy Reporting Communicable Disease
 
Develop/Review/Revise internal policies and procedures, to stock up on environmental cleaning agents, and personal protective equipment as necessary. (Include facility’s medical director, Director of Nursing, Infection Control Practitioner, safety officer, human resource director, local and state public health authorities, and others as appropriate in the process.
–       The following departments have input in selecting, acquiring and reviewing the policies for obtaining needed supplies: Medical Director, Director of Nursing, Infection Control Nurse, Human Resources, Director of Environmental Services, Procurement Officer.
–       Chapin Home has developed a policy for optimizing PPE and will be cognizant of emerging pathogens and illnesses at the time of the pandemic and plan to handle the worst-case scenarios without incurring shortages.
–       Chapin Home has established par level for PPE utilizing data for a week’s period during April. The facility has identified a secure storage area for minimum 60-day supply of PPE. Supplies maintains include:
1.     Isolation Gowns
2.     Gloves
3.     Face Masks
4.     Face shields
5.     Eye protection 
6.     N95 respirators
7.     Sanitizer and disinfectants in accordance with current EPA guidance
 
             ► Please refer to Policy Pandemic Optimizing PPE
             ► Please refer to Policy Cleaning and Disinfection of Environmental Services 
 
Develop/Review/Revise administrative controls (e.g., visitor policies, employee absentee plans, staff wellness/symptoms monitoring, human resource issues for employee leave).
–       All sick calls are monitored by Human Resources and/or designee in conjunction with the Infection Control Nurse to identify any staff pattern or cluster of symptoms associated with an infectious agent/illness.
–       All staff has been educated to self-assess and report symptoms of pandemic illness before reporting to duty and to report finding immediately to their Department Head.
–       The facility has developed a policy for visitation based upon knowledge of community occurrence of pandemic illness and regulatory guidance.
–       Chapin Home has developed a health screening questionnaire and temperature checks to be done upon entrance to the facility for all employees, contract staff, vendors, and visitors during pandemic emergency.
 
            ► Please refer to Policy Healthcare Services Group Staffing
            ► Please refer to Policy Pandemic Emergency Staffing
            ► Please refer to Policy Visitation, Infection Control during a Pandemic
 
Develop/Review/Revise environmental controls (e.g., areas for contaminated waste).
–        Housekeeping Department will be trained on handling of contaminated waste and will be given proper PPE to utilize when performing these tasks.
–       Chapin Home policy on biohazardous waste will be reviewed and revised as needed related to any new infectious agent and/or mode of transmission.
 
          ► Please refer to Policy Isolation – Pandemic Removing a Body
 
Develop/Review/Revise vendor supply plan for re-supply of food, water, medications, other supplies, and sanitizing agents.
–       Chapin Home Dietary Director and/or designee monitors on a quarterly bases and maintains a 4-day emergency supply of food and water to ensure it is intact and safely stored.
–       Chapin Home will ensure to maintain adequate supply of stock medication for 60 days.
–       As required by NYSDOH, the facility has access to and will maintain 60 days of sanitizer and disinfectant supplies.
–       It is the responsibility of the Department Heads and/or designees to monitor the departments emergency supplies and will notify the Procurement Officer and or Administrator of any specific shortages or needs.
 
          ► Please refer to Policy Pandemic, Emergency Supplies
 
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.
–       Chapin Home has implemented a plan of utilizing a designated unit for cohorting confirmed and/or suspected residents.
–       Residents within the designated unit will be separated by wing for positive and a wing for first step negative.
–       The dedicated unit will have dedicated cohorted staff who will not float and/or be assigned to other units.
–       Symptomatic resident(s) and their exposed roommate will be confined to their room and/or suspected units if resident co-mobility does not allow or limits resident understanding of room confinement.
–       Closure of unit symptomatic resident(s) resides (includes restricting all resident on the affected unit, regardless of symptoms)
–       Resident condition will be monitored and if deemed necessary will be transferred to the hospital during a pandemic emergency based on their infection status in accordance with applicable NYSDOH and CDC guidelines.
–       Residents requiring transfer to a higher level of care will have their infectious status, cohorting status and mode of transmission precautions documented on transfer documents.
 
► Please refer to Policy Pandemic Suspected or Confirmed
► Please refer to Policy Pandemic Hospital transfer
 
Develop plans for cohorting, including using of a part of a unit, dedicated floor, or wing in the facility or a group of rooms at the end of the unit, and discontinuing any sharing of a bathroom with residents outside the cohort.
–       Chapin Home has a dedicated floor, or wing in the facility or a group of rooms at the end of the unit. This dedicated area will be divided by doors, the designated cohort area will not share bathroom/showers with residents outside the area.
–       Signage has been placed on doors and entrances to clearly identify area and admittance requirements.
–       All attempts will be made to have dedicated staff assigned to each cohort group and to minimize the number of different caregivers entering the rooms.
 
Develop/Review/Revise a plan to ensure social distancing measures can be put into place where indicated (describe facility’s process, e.g. which non-essential activities to eliminate, changes in dining/other physical space arrangements involving residents/staff, etc.)
–       Chapin Home has implemented social distancing measures can be put into place where indicated (describe facility’s process, e.g. which non-essential activities to eliminate, changes in dining/other physical space arrangements involving residents/staff, etc.
–       Social distancing signage has been placed in all high traffic common spaces (e.g. front door, lobby, employee dining room, employee locker, outdoor benches)
–       Signage has been placed on flooring noting social distancing (e.g. time clock areas, lobby, entrance areas)
–       Employees breaks and lunch times have been staggered to accommodate social distancing, including non-clinical admin staff eating at workstations. 
–       Chapin Home will review, and revise policies and procedure related to recreational activities during a pandemic to ensure social distancing is adhered to in accordance to NYSDOH guidelines and CDC recommendations.
–       Chapin Home communal dinning program will be reviewed and revised to ensure social distancing is adhered to in accordance to NYSDOH guidelines and CDC recommendations during the pandemic emergency.
–       Staff have been and will continue to be educated on social distancing practices.
 
Develop/Review/Revise a plan to recover/return to normal operations when, and 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. 
–       Chapin Home will adhere to directives by the NYSDOH 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. 
–       Chapin Home will maintain communication and follow guidelines and/or directives from NYSDOH, CMS, CDC for returning to normal operations.
–       Chapin Home’s website will be updated when restrictions are lifted and normal operation resume.
–       Resumptions of routine consultation will be made on a case by case basis and upon medical necessity and exposure risk.
–       Chapin Home continues to comply with testing as ordered by the NYS DOH, when the facility meets recommended guidelines for reopening; notification will be issued to families and residents.
 
In accordance with PEP requirements, Develop/Review/Revise a Pandemic Communication Plan that includes all required elements of the PEP.
–       Social Work and Resident Relation Representative will ensure that there is an accurate list of each resident’s representative with preference for type of communication.
–       Human Resources and/or IT Director will update facility web site on identification of any infectious disease outbreak or upon facility notification of community pandemic.
–       Chapin Home will utilize robocall, email, mailing, internet, phone calls and signage to alert, residents, resident representative, visitors, employees about the status of the infectious disease in the facility/community.
 
► Please refer to Policy Pandemic Communication Plan
► Please refer to Policy Robocall
► Please refer to Policy Pandemic Suspect or Confirmed
 
In accordance with PEP requirements, Development/Review/Revise plans for protection of staff, residents and families against infection that includes all required elements of the PEP.
–       Chapin Home has developed a Plans for Protection which includes:
1.     Staff and resident education
2.     Screening of residents, staff, vendors, and contracted employees
3.     Screening of resident on admission
4.     Proper use of PPE
5.     Implementing social distancing
6.     Cohorting of staff and residents
7.     Testing of residents and staff
8.     Surveillance of residents
9.     Visitor restrictions in accordance with NYSDOH and CDC
 
            ► Please refer to Policy Infection Control and Program
            ► Please refer to Infection Prevention Policies and Procedure – Pandemic
             ► Please refer to Policy Infectious Disease Threat, Training and Education
 
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 diseases.
–       Chapin Home 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.
–       Signage will be posted by the ICN and/or designee throughout the facility which will include information on newly emergent infectious disease, advisories, symptoms and mode of transmission.
–       The ICN and/or designee will monitor and ensure appropriate signage is visible in the facility at key locations: entrances, time clocks, informational TV monitor and/or unit information boards, break room, etc.
 
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. 
–       Chapin Home will meet all requirements for reporting of suspected and confirmed communicable disease as mandated under the New York State Sanitary Code (10 NYCRR 2.10 Part2) as well as by 10 NYCRR 415.19.
–       Director of Nursing and/or designee will be responsible to report communicable diseases via the NORA reporting system on the HCS.
–       ICN and/or designee will be responsible to report communicable diseases on the NSHN as directed by CMS.
 
► Please refer to Policy Reporting Communicable diseases
 
The facility will assure it meets all reporting requirements of the Health Commerce System, e.g. HERDS survey reporting.
–       The facility will ensure all reporting requirement to the HCS (daily HERDS survey report) is met by assigned staff and/or designee
–       Director of Nursing and/or designee will be responsible to report communicable diseases via the NORA reporting system on the HCS.
 
► Please refer to Policy Reporting Communicable disease
 
The Infection Control Practitioner will clearly post signs for cough etiquette, hand washing, and other hygiene measures in high visibility areas. Consider providing hand sanitizer and face/nose masks, if practical.
–       The Infection Control Nurse will clearly post signs for cough etiquette, hand washing, and other hygiene measures in high visibility areas.
–       Chapin Home promotes good hand washing/hygiene through education and signage throughout the facility including rest rooms, entrances, elevators, and informational TV monitor.
–       Chapin Home promotes and encourages all residents, residents’ representatives and/or guardians through education and signage in resident’s bathrooms/toileting area and sink in a form that meet cognitive needs of the residents.
–       ICN, In-Service coordinator and/or designees review and complete hand hygiene competencies with all department staff, contracted employees and physicians, findings are reported to QAPI committee.
–       Chapin Home will ensure bathrooms and other hand washing areas are well stocked with hand soap and paper towels.
–       Alcohol-based hand sanitizers dispensers are located throughout the facility at the following locations: all entrances/exits, on each unit outsides of elevators/stairwells access, rehab gym; by time clock, outside employee lunchroom. Hand washing station are location in all public restrooms, resident rest room, employee lunchroom, medication rooms, laundry room, rehab gym, employee lock room. Hand sanitizers are located at front desk, medication carts.
 
The facility will implement the following procedures to limit exposure between infected and non-infected persons and consider segregation of ill persons, in accordance with any applicable NYSDOH and CDC guidance, as well as with facility infection control and prevention program policies.
–       Chapin Home will 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.
–       Upon identifying any infectious process/status, Chapin Home will implement cohorting policies.
–       Chapin Home will monitor all residents to identify infection or symptoms of infectious agent.
–       When infectious agent is identified on a unit, the unit will be quarantined, admission limited and staff cohort to the unit based on guidance from NYSDOH and CDC.
–       Chapin home will follow guidance and restrictions from NYSDOH regarding visitation, communal dining, activities and testing.
 
The facility 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:
–       The facility 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.
–       Chapin Home will monitor staffing, giving priority to the use of returning staff as part of the cohorted staff team to care for residents experiencing the same infectious event.
 
The facility 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. 
–       Chapin Home will conduct cleaning/decontamination in response to the infectious disease in accordance with any applicable NYSDOH, EPA and CDC guidance.
–       Housekeeping Services during a pandemic/infectious event will increase cleaning of high touch areas throughout the facility.
 
            ► Please refer to Policy Cleaning and Disinfection of Environmental
 
The facility will implement the following 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:
–       The facility will implement the following procedures to provide residents, relatives, and friends with education about the disease and the facility’s response strategy at a level appropriate to their interests and need for information.
–       All residents and families will receive ongoing information on the infectious agent, transmission, prevention measures and any changes in the facility policies. This will be provided to residents via posting on units, provided to resident via virtual meeting. This will be provided to families via robocall, mailings and phone calls.
 
►Please refer to Policy Pandemic Communication Plan
 
The facility will contact all staff, vendors, other relevant stakeholders on the facility’s policies and procedures related to minimizing exposure risks to residents provide information regarding facility-maintained list of external stakeholders to be contacted and mechanisms for sharing this information 
–       Chapin Home will contact all staff, vendors, other relevant stakeholders on the facility’s policies and procedures related to minimizing exposure risks to residents provide information regarding facility-maintained list of external stakeholders to be contacted and mechanisms for sharing this information.
–       Chapin Home will follow visitor restrictions as per NYSDOH guidance. Restriction information and updates will be posted on Chapin Home website and at the entrance to the facility.
–       PPE will be provided and wore during any scheduled compassion visit permitted during the pandemic. Visitor will be screened and provided with written guidelines for visitation requirements, to minimize exposure, the importance of frequent hand hygiene, and donning/doffing of PPE.
–       Medical consultants that service our residents will be notified and arrangements will be made for telehealth or postponing evaluation unless medically necessary.
–       When possible, vendors will be required to drop off deliveries at designated areas to avoid entrance into the facility.
–       If any vendors should need to enter the facility, vendors temperature will be taken, and delivery will be dropped at the ground floor and/or front desk.
 
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 implement the following procedures to close the facility to new admissions, limit visitors when there are confirmed cases in the community and/or to screen all permitted visitors for signs of infection:
–       The facility will follow all applicable NYS Executive Orders and/or NYSDOH guidance in pandemic emergency on visitation restrictions.
–       Chapin Home will limit and/or restrict visitors as per guidelines from the NYSDOH
–       All restriction or changes to the facility visitation policy has been posted on the Chapin Home website, front door and communicated to all residents and designated representatives.
–       Chapin Home has developed a policy and procedure for screening and thermal temperature check upon entry to the facility for all employees, contract staff, vendors, during pandemic emergency.
–       Chapin Home will quarantine units and suspend admissions based upon guidance from the NYSDOH and CDC.
–       Chapin Home will continue to monitor the community level on the CMS website.
 
Ensure staff are using PPE properly (appropriate fit, don/doff, appropriate choice of PPE per procedures)
–       Chapin Home will ensure staff are using PPE properly (appropriate fit, don/doff as per procedures)
–       Staff will be in-services during on boarding process, annual and as deemed necessary
–       Each unit has a designated area stock with PPE (face mask, gowns) available each shift.
 
In accordance with PEP requirements, the facility will follow the following procedures to post a copy of the facility’s PEP, in a form acceptable to the commissioner, on the facility’s public website, and make available immediately upon request:
–       A copy of the facility PEP will be posted in a form acceptable to the commissioner on the facility website and made available immediately upon request by 9/15/20
–       The PEP will be available will be available on the facility shared drive.
 
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:
–       Chapin Home will communicate with residents and resident’s representative as per their preference.
–       During a pandemic emergency, representative of residents with infectious agent will be notified daily and with significant change by medical staff as to their status.
–       All resident representatives will be notified weekly on the on the status of the pandemic at the facility which includes the number of pandemic infections and deaths, including residents that expire for the reason other than such infection (e.g. infected with infectious agent but who expire for reason other than infectious agent).
–       Updates will be given to residents and resident representatives within 24 hours indicating any newly confirmed cases and/or death related to the infectious agent.
–       All residents will be provided with daily access to communicate with their family member and/or guardians. The type of communication will be based upon the resident’s preference (i.e. video calling, telephone call, through the window visit and/or email.)
 
    ► Please refer to Policy Pandemic Communication Plan
 
In accordance with PEP requirements, the facility will implement the following procedures/methods to ensure that all residents and authorized families and guardians 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:
–       All resident representatives and/or guardians will be notified weekly on the status of the pandemic at the facility which includes the number of pandemic infections and deaths, including residents that expire for the reason other than such infection (e.g. infected with infectious agent but who expire for reason other than infectious agent).
 
► Please refer to Policy Pandemic Communication Plan
 
In accordance with PEP requirements, the facility will implement the following mechanisms to provide all residents with no cost daily access to remote videoconference or equivalent communication methods with family members and guardians:   
–       All residents will be provided with daily access to communicate with their family members and/or guardians at no cost to the residents to remote video conference or equivalent communication with family members and/or guardians.
–       The Activities Director and/or designee will be responsible to arrange time for all videoconferencing.
 
► Please refer to Pandemic Communication Plan
 
In accordance with PEP requirements, the facility will implement the following process/procedures to assure hospitalized residents will be admitted or readmitted to such residential health care facility or alternate care site after treatment, in accordance with all applicable laws and regulations, including but not limited to 10 NYCRR 415.3(i)(3)(iii), 415.19, and 415.26(i); and 42 CFR 483.15(e): 
–       Chapin Home has implemented the 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).
–       The admission team will review hospital records to identify resident needs, exposure to risk to infectious agent, and the facility’s ability to provide care including cohorting and treatment needs.
 
► Please refer to Policy Admission, Transfer and Discharge
 
In accordance with PEP requirements, the facility 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):
–       Chapin Home has implemented a 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):
 
► Please refer to Policy Admission, Transfer and Discharge
 
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 (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)
 
–       Chapin Home has implemented 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.
          This includes, but is not limited to:
1.     N95 respirators
2.     Face shields
3.     Eye protection
4.     Gowns/isolation gowns
5.     Gloves
6.     Face Masks 
7.     Sanitizers and disinfectants (meeting EPA Guidance current at the time of the pandemic)
 
–       The facility will calculate daily usage/burn rate to ensure adequate supply of PPE.
 
 
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.
–       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.
–       The facility will document recovery events on a tracking log.
 
The facility will communicate any relevant activities regarding recovery/return to normal operations, with staff, families/guardians and other relevant stakeholders
–       Chapin Home will communicate any relevant activities regarding recovery/return to normal operations, with staff, families/guardians and other relevant stakeholders
–       During the recovery phase, all residents, staff and contracted employees will be monitored and tested to identify any developing symptoms related to infectious agent in accordance with NYSDOH and CDC guidance.
 
► Policies will be available for review upon require