• This Pandemic Emergency Plan is prepared in accordance with the NYSDOH requirement as detailed in DAL NH 20-09 dated 8/20/20 and is added to and a component of Bishop Rehabilitation Emergency Preparedness Plan last reviewed and updated on 05/03/24
  • The Pandemic Emergency Plan will be reviewed annually and modified as needed.
  • The Pandemic Emergency Plan will be activated when a Pandemic is declared by either Federal (CMS or HHS) or State (NYSDOH) authorities.
  • The Pandemic Emergency Plan is currently activated as a result of the COVID-19 Pandemic
  • PEP implementation date: 09/14/20    
  • Annual scheduled review date: 09/01/24

Pandemic Communication Plan

Pandemic Emergency Preparedness Plan Availability  

  1. An electronic copy of this Pandemic Emergency Plan (PEP) will be posted on the facility’s public website
  2. Upon request, additional copies of this Pandemic Emergency Plan (PEP) will be provided

Resident Condition - Communication

  1. The facility will update the authorized family members and/or Health Care Proxy/Guardians of each resident infected with a pandemic-related infection (i.e. that tested positive for COVID-19):
    1. At least daily
    2. Upon a change of condition
    3. The update will cover the current medical condition and any changes noted.
    4. The facility will work to accommodate specific family communication requests, including alternative communication methods
  2. The facility will update all families/responsible parties of residents as needed on the following:
    1. The total number of residents currently infected with a pandemic-related infection
    2. The total number of resident deaths resulting from a pandemic-related infection, including residents that tested positive for a pandemic-related infection but who pass away for reasons other than such infection
  3. The weekly update will be done via posting on the facilities website on the same day each week before 5 pm
  4. The facility will send a letter to all the families informing them about updates as needed.

Resident-Family communication

  1. During a Pandemic the facility will make available the following electronic devices to allow for regular communication between residents and family/responsible parties:
    1. Sufficient electronic tablets with video capability to allow residents and their families/responsible parties to have virtual visits via videoconferencing
    2. Internet connection
    3. The facility will appoint a point person to schedule videoconferencing times and assist residents in accessing the video conference application
    4. The facility will send out a letter to all families/responsible parties with all the pertinent details, including which video application is being used, who the facility contact person is at the facility, and how to schedule a videoconference,
    5. The electronic tablets will be kept in a secure location to ensure that they are no broken, lost, or stolen
    6. The electronic tablets and internet connection will be provided at no cost to the resident or families/responsible parties

Family Stake Holder Education

  1. The facility will post links to education material regarding the Pandemic Infectious Disease
  2. The facility will post this PEP to allow families to see the facility’s response strategy


Infection Protection Plan

Infection Control Plan for Admission/Readmission

  1. New Admissions and Readmissions (also see page 3 “readmitting”) from a hospital setting:
    1. Will be placed on isolation for 14 days (see COVID-19 Manual for policies on new admissions and cohorting)
    2. Will be closely monitored for sign and symptoms of pandemic-related infection
    3. Staff providing care will wear appropriate PPE per isolation policy and as directed by NYSDOH
    4. Signs will be posted outside of room notifying/reminding staff to wear PPE and disinfect between rooms
    5. To the extent possible new admissions/readmissions will be cohorted together in one section of a unit to minimize potential exposure (see Cohort Plan below for more details)

Cohort Plan

  1. The facility will create 4 cohort zones of dedicated rooms/units in order to reduce possible exposure and transmission. The designated cohort zones are:
    1. Positive – for residents who test positive for the pandemic-related infection
    2. Negative – for residents who test positive for the pandemic-related infection
    3. Unknown – for residents that do not exhibit symptoms but have not tested negative
    4. New Admission – within 14 days of admission or readmission after a hospital admission
  2. The facility will determine the area of each cohort zone based on the following:
    1. A cohort area may be a complete unit or a section of a unit depending on:
      1. The number of residents in each cohort at the time (this may change as infection rate changes)
      2. Facility layout/unit layout
  • Bathroom availability
  1. Staffing considerations
  1. If only a small number of residents test positive for the pandemic-related infection those residents will be cohorted together in one area in a designated block of rooms to minimize exposure and transmission
  2. Each cohort zone will have sufficient bathrooms for the residents residing in that zone
  3. Residents will not be able to use bathrooms outside of their own zone
  1. Cohort zones should be clearly designated (i.e. colored tape on floor or wall signage) to ensure employee compliance with appropriate PPE usage and prevention of travel from one zone to another
  2. Signs should be posted in each zone indicating appropriate PPE usage level
  3. Doors should be closed between units to prevent outside residents from entering other zones
  4. If only one section of a unit is designated as a separate cohort zone, a visual barrier should be placed to remind staff and residents not to cross and staff should be alert in order to prevent
  5. Develop staffing patterns for effective cohorting:
    1. Minimize staff transfer between cohorting zones, wherever possible
    2. Bundle care of residents in same cohort zone before moving on to another zone
    3. Establish a PPE donning and duffing
    4. Ensure sufficient hand sanitizer and disinfectant between cohorting zones

Managing Cohort Zones

  1. Utilize the infection control electronic bed board (color coded for each zone) to enable efficient tracking and cohorting of residents
  2. Cohorting review process (see COVID-19 Manual Cohort policy and procedure)
    1. A resident that tests positive for a pandemic-related infection will be immediately transferred to Positive area
    2. Roommate of newly infected resident placed on isolation precautions and monitored closely for signs and symptoms
    3. Electronic bed board utilized for tacking isolation time – to be reviewed daily
    4. Weekly review of all residents to ensure proper cohorting and planning for residents set to graduate from isolation or Positive Zone
  3. Resident transfer process:
    1. Disinfect both rooms before and after transfer
    2. Safe transfer of resident’s belonging to prevent transmission of infection using bags to cover belongings
    3. Nurse to nurse handoff
    4. Medication reconciliation
    5. Update of bed board and medical chart
  4. In case of an emergency or significant outbreak where the facility cannot maintain the cohorting zones the facility will:
    1. Contact corporate clinical and operational support to secure increased staffing, supplies, or other such items necessary to maintain care and proper cohort at the facility
    2. Contact sister facilities for staff and/or supplies
    3. If after all support options are exhausted, the facility will contact NYSDOH and local county DOH for support and further guidance

Social Distancing – Reducing potential exposure

  1. In order to ensure social distance regulations are adhered to:
    1. Suspend communal dining and activities, per NYSDOH and CMS guidance/regulations
    2. Establish protocols for resident transfers
    3. Outdoor activities, such as smoking, limited to only a few residents at a time to allow for social distancing between residents
    4. Where possible, place indicators such as stickers or a line of tape to indicate social distancing space
    5. Employee breakroom should be limited to allow for social distancing space
    6. Employees will be educated to keep social distancing even while on break





Readmitting Hospitalized Residents  

  1. In accordance with all applicable NYS DOH and Federal Bed-Hold regulations and the facilities Bed-Hold polices; during a Pandemic the facility will assure residents hospitalized due to the pandemic disease will be readmitted to the facility when:
    1. Their level of care can be safely managed at the facility
    2. There is an appropriate bed available taking into account:
      1. Positive infections and cohorting zones
      2. Specialized care units
  • Behavior/locked units
  1. The facility will inform the hospitalized residents and families/responsible parties of this policy together with the regular bed hold policy that is given to residents and families
  2. Additionally, in accordance with all applicable NYS and Federal Bed-Hold regulations and the facilities Bed-Hold polices, during a Pandemic the facility will attempt to preserve a resident's place, if appropriate:
    1. Admit new residents to other open beds first, taking into account the following:
      1. Gender – roommate and shared bathroom (between rooms) considerations
      2. Infection control (including other infections) and cohorting considerations
  • Psychosocial considerations
  1. Returning resident readmissions will not be able to return to their place before 14-day isolation

Securing a 60-day supply of PPE

  1. Ensure minimum of 60-day supply of Personal Protective Equipment (PPE) is available
    1. Review current supply and average daily usage of PPE with Director of Nursing and Medical Director
    2. Review NYSDOH guidance on PPE usage and regulations and CDC PPE burn rate calculator
    3. Arrange for a minimum of 60-day stockpile of PPE including:
      1. N95 respirators
      2. Face shield
  • Eye protection
  1. Gowns/isolation gowns
  2. Gloves
  3. Masks
  • Sanitizer and disinfectants (meeting EPA Guidance current at the time of the pandemic)
  1. Identify a secure location for storage of PPE
    1. Secure Location: Central Supply
  2. Establish regular weekly delivery service of depleted PPE supply in order to preserve 60-day supply
  3. Establish protocols for supply rotation
  4. Arrange for back-up delivery services in case of supply or logistical disruption of regular supply chain
  5. PPE burn rate may be pathogen specific, including item specific. Review DOH guidance and observed usage to modify burn rate calculation to ensure sufficient PPE supply
  6. COVID-19 Pandemic – per NYSDOH regulations the facility will have a 60-day PPE supply by 9/30/20

Staff education on infectious diseases

  1. The facility will provide education for all employees on the following:
    1. Infection control – Basics prevention of communicable diseases
    2. Pandemic-related specific infection control
    3. Risk of exposure/transmission and need for PPE use
    4. PPE guidance and usage
      1. Proper technique for donning and doffing
      2. Level of appropriate PPE
    5. Housekeeping and disinfection process
    6. Pandemic infectious disease symptoms (e.g. COVID-19 symptoms)
    7. Regulations pertaining to the pandemic infectious disease, including but not limited to,
      1. Travel restrictions
      2. Health screening requirements
  • Testing requirements
  1. Masks and other PPE requirements
  2. Social Distancing for staff and residents
  3. Suspension of Visitation
  1. Regulatory reporting requirements for the pandemic infectious disease
  1. All new hires will receive the above education at time of orientation
  2. Infection Control posters will be distributed in key locations around the facility reminding/education staff about the following:
    1. Handwashing
    2. Mask wearing
    3. PPE Donning and Duffing
    4. Cough etiquette
  3. The facility will develop cleaning and disinfecting policies related to the Pandemic Infectious Disease
  4. The facility will educate all housekeeping staff on the methods and products necessary to disinfect surfaces from the Pandemic Infectious Disease as outlined in the policies

Communicable Disease Reporting

  1. The Administrator, Director or Nursing and Infection Preventionist will review reporting requirement for suspected or confirmed communicable diseases as mandated under NYSDOH Regulated Article 28, New York State Sanitary Code (10 NYCRR 2.10 Part 2), as well as by 10 NYCRR 415.19.
  2. See Annex K of the CEMP toolkit (attached) for complete reporting requirements including list of diseases
  3. The facility will ensure that the following staff members have access to Health Commerce System (HCS), Nosocomial Outbreak Reporting Application (NORA) and HERDS surveys:
    1. Administrator
    2. Assistant Administrator
    3. Director of Nursing
    4. Infection Preventionist
    5. Assistant Director of Nursing.
  4. The facility will educate all the above listed staff members on the reporting requirements and specific reporting methods of the NORA, HERDS and NHSN reports
  5. The DON/Infection Preventionist will be responsible to report communicable diseases via the NORA reporting system on the HCS
  6. The Administrator will be responsible to complete all required HERDS survey reporting
  7. The Administrator will arrange and train an alternate staff member to complete the HERDS survey reporting if they are absent or otherwise unavailable
  8. Should personnel changes occur, the replacement staff member will be provided with log in access and training for HCS, NORA and HERDS Survey applications
  9. All cases, including a single case, of a communicable or unusual disease will be reported to the local county health department (LHD) within 24 hours

NYSDOH and CMS Updates

  1. The facility will ensure it receives all NYS DOH and CMS Pandemic related updates
    1. Regular check of the HCS website for updates
    2. Regular check or CMS website for updates
    3. Sign up for email updates from HCS and CMS
    4. Regular check of industry communication websites

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

  1. Develop a comprehensive Pandemic Infectious Disease Manual (e.g. COVID-19 Manual) that includes sections addressing
    1. Infection prevention techniques and policies
    2. Infection control techniques and policies
    3. Cohorting policies
    4. Local, State, and Federal reporting guidelines
    5. Cleaning and disinfecting techniques and policies
  2. If a Pandemic Infectious Disease Manual already exists and a Pandemic is declared review and revise as needed

Conduct routine/ongoing, infectious disease surveillance

  1. The facility will test all employees, including agency staff and vendors on a frequency required by the NYSDOH or CMS
  2. The facility will screen all employees, including agency staff and vendors as required by the NYSDOH or CMS
  3. The facility will establish a daily resident assessment tool for early dedication of signs and symptoms of infection
  4. The facility will keep a Pandemic Infectious Disease infection control line listing and tracking tool to monitor any increase of rate of infection

Plan for staff testing and laboratory services

  1. Develop an electronic tracking tool for employee and residents testing
    1. Efficient way to track which staff still need to be tested
    2. Color system (Green, Yellow, Red) based on most recent test and date of next required test
    3. Weekly compliance report
  2. Contract with a diagnostic lab to capable of handling the frequency of testing required, including timely results as required by NYSDOH or CMS
  3. Establish drop off and/or shipping process for lab tests

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

Sufficient medications

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

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

  1. Review current supply and weekly usage of environmental cleaning agents with the Director of Housekeeping and Laundry and Director of Dietary (for kitchen cleaning agents)
  2. Review with Medical Director additional environmental cleaning agents needed as a result of the Pandemic
  3. Review current supply and weekly usage of all standard non-medical supplies
  4. Calculate and purchase sufficient amount to equal a 30-day supply
  5. Identify a secure, safe, location for storage of environmental and dietary chemical
    1. Secure Location: Laundry cage
  6. Develop contingency plan with environmental, dietary cleaning agent and non-medical supply vendors in case of travel restrictions due to a Pandemic

60-day supply of Personal Protective Equipment (PPE)

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

Sufficient food and water

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


Administrative controls to help prevent infection at the facility

Facility Visitation

  1. Follow NYSDOH, CMS and CDC guidance regarding family/friends’ resident visits
    1. If directed by NYSDOH or CMS - halt all visits except end of life
      1. Notify all families of the new guidance
      2. Set up electronic video conference for virtual visit (see Page 1)
    2. When NYSDOH allows the resumption of visits - Develop a safe visitor policy
      1. Develop a visitor Health screen tool per NYSDOH, CMS and CDC guidance, may include temperature check and hand disinfecting
      2. Electronic record of all visitors to allow for contact tracing in case of a subsequent outbreak
      3. Social distancing plan and daily maximum of visitors
      4. Halt visits if a resident or facility employee tests positive for the Pandemic Infectious Disease or if directed by NYSDOH or CMS as a result of an increase in the local community infection rate
      5. See Page 9 for resumption and recover to normal operations

Staff Screening

  1. Develop and install a comprehensive staff health screening tool
  2. Follow NYSDOH CMS and CDC guidance regarding the health screen questionnaire, temperature check, and use of hand disinfectant
  3. Set up one location for staff entry to ensure all staff are screened prior to beginning work

Emergency Staffing

  1. Create an emergency staffing contingency plan that includes, but not limited to:
    1. Contacting outside nursing support agencies to alert them of a pending need
    2. Contacting corporate staffing support to identify sister facilities that have the ability lend staff in an emergency
    3. Creating an Emergency staffing ADL care schedule to guide nursing staff on how to prioritize ADL care in a severe staffing situation
    4. Arranging for emergency training of non-clinical staff and set up a work flow for them to work alongside clinical staff on items such as making beds, wheeling residents to dining, passing food trays etc. (non-personal care)

New Admissions

  1. If as a result a Pandemic the NYSDOH or CMS directs the facility to stop all new admissions:
    1. Inform the hospital and other discharge locations of the new order
    2. Inform admissions and marketing staff to halt all admissions



Environmental controls

  1. Review contract with licensed vendor for contaminated waste disposal to ensure it is current
  2. Areas for contaminated waste are clearly identified as per NYSDOH guidelines
  3. The facility will follow all Department of Environmental Conservation (DEC) and DOH rules for the handling of contaminated waste.
  4. The onsite storage of waste shall be labeled and in accordance with all regulations.
  5. Staff involved in handling of contaminated product shall be trained in procedures prior to performing tasks and shall be given proper PPE
  6. The facility will amend the Policy and Procedure on Biohazardous wastes as needed related to any new infective agents.
  7. Refer to Policy and Procedure on Handling of Biohazardous Waste Material

Develop a plan to recover/return to normal operations

  1. The facility will adhere to all regulations and directives as specified by NYSDOH, CMS, and CDC at the time of each specific infectious disease or pandemic event regarding how, when, which activities/procedures/restrictions may be eliminated, restored and the timing of when those changes may be executed.
  2. The facility will maintain communication with the NYS DOH and CMS and follow guidelines for returning to normal operations.
    1. Regular check of the HCS website for updates
    2. Sign up for email updates from HCS and CMS
  3. The decision to resume outside consultant visits will not be made before express direction from the NYSDOH and on a case by case basis taking into account medical necessity and infection levels in the community.
  4. The decision to resume family/friend visitation will not be made before express direction from the NYSDOH and on a case by case basis taking into account medical necessity and infection levels in the community.
  5. Families, responsible parties and guardians will be notified of impending visitation changes, recovery and return to normal operations via electronic notification on the facilities website
  6. During the recovery period residents and staff will continue to be monitored daily in order to identify any symptoms that could be related to the Pandemic Infectious Disease