Helen Hayes Hospital Resident Health Care Facility and Transitional Care Unit Pandemic Emergency Plan

September 15, 2020

Resident Health Care Facility and Transitional Care Unit Pandemic Emergency Plan 


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. 

The Helen Hayes Hospital Residential Health Care Facility and Transitional Care Unit follows effective strategies for preventing infectious diseases and has developed the following Pandemic Emergency Plan (PEP). The PEP will be posted to the facility’s website at www.helenhayeshospital.org and updated when applicable. The PEP will also be provided immediately upon request to the Administrative Office. 


Education is provided to facility staff annually and on an as needed basis for all clinical staff on infectious diseases, isolation, and the personal protective equipment (PPE) required for the infectious disease as well as proper donning and doffing. 

Infection Prevention: 

To protect staff, residents and families against infection, following Center for Disease Control (CDC) and Department of Health (DOH) guidelines, protocols have been developed by Administration, Medical Staff and Infection Prevention and will be updated as applicable. 

A protocol is in place to manage confirmed, suspected or exposed pandemic residents. This protocol follows the DOH and CDC guidelines related to testing, quarantine, and PPE use. 

The Laboratory will notify Infection Prevention and unit staff of any positive infectious diseases. Confirmed positive residents are relocated to designated private rooms on a unit or to the pandemic unit and placed on appropriate isolation promptly. All residents are tested on admission for COVID- 19 and remain on contact and droplet precautions pending results. 

The Infection Prevention Nurse is notified immediately of a positive result for any infectious disease, investigates promptly and uses line listings to track prevalence. The Infection Prevention Nurse will report these to regulatory agencies, as well as to Hospital committees, as appropriate or required. Helen Hayes Hospital Resident Health Care Facility and Transitional Care Unit Pandemic Emergency Plan 

The facility will report all required communicable diseases via Nosocomial Outbreak Reporting Application (NORA) in conjunction with notification of local and/or regional Department of Health departments as mandated under New York State Code (10 NYCRR 2.10 Part 2), as well as by 10 NYCRR 415.19. 

The facility’s Health Commerce System (HCS) Coordinators will ensure that all HCS directories, contact persons, roles and other required information are maintained current and active to access communicable disease reporting tools and other outbreak specific reporting requirements. HCS communications are coordinated by Administration to ensure that a staff member has been assigned the primary responsibility of responding to the communication, with additional staff members assigned to ensure completion of all reporting requirements. 

The facility has a Building Maintenance System (BMS) which allows automatic or manual control of the facility’s heating, ventilation and air conditioning (HVAC). During an infectious disease/pandemic emergency, Helen Hayes Hospital has the ability to exhaust 100% of all return air and supply 100% fresh air to patient care rooms in the facility. 

Each patient wing is able to maintain negative pressure to common hallways under the above circumstance. 

Dirty utility rooms where waste is disposed of is maintained in a negative pressure relationship to patient hallways. 

Employees will utilize an electronic screening tool prior to arrival to work or in-person screening tool upon staff’s arrival to work to identify illness. 

As a precautionary measure or as directed by a New York State Executive Order and/or New York State Department of Health guidance, visitation will be prohibited or limited to reduce exposure risk to residents and staff. If visitation is permitted, a visitation plan will be posted to the facility’s website and Facebook page and provided to the visitor upon arrival. All visitors will be required to wear a face mask at all times while in the facility. All visitors will be screened upon entrance to the facility for signs and symptoms of illness including temperature check. 

In addition, volunteers, support groups, students and Wellness Center participants will be restricted. 

To ensure social distancing measures: 

• If applicable, reduction in the workforce will commence and will be determined by Administration. 

• Social distancing markers will be placed throughout the facility. 

• Work areas will be reconfigured for staff returning from workforce reduction. 

Supply / Personal Projective Equipment: 

Inventory and sustainability of resources and assets located on the campus are conducted as part of the facility’s Emergency Operations Plan. Sharing resources with other healthcare organizations within the region is predetermined by the Mutual Aid Agreements. Helen Hayes Hospital Resident Health Care Facility and Transitional Care Unit Pandemic Emergency Plan 

An inventory of established levels of food, water and paper supplies for an emergency/pandemic purposes will be maintained in the facility’s storeroom. An up-to-date listing of all vendors will be maintained, including contact numbers and products they supply in the event an emergency supply order is needed. 

Critical supply status including personal protective equipment (PPE) and environmental cleaning agents are monitored on a daily basis. 

Central Supply is in frequent contact with vendors for supplies. If the facility receives PPE from the state in response to shortages, these products are reviewed by Infection Prevention for appropriateness for use by clinical staff. 

In instances where the facility experiences shortages of cleaning agents, acceptable replacement products will be used for environmental cleaning based on availability. 

The facility will monitor the inventory of personal protective equipment daily. To maintain at least a 60-day supply of personal protective equipment 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, contracted vendors as well as miscellaneous vendors are contacted regularly to supplement any required items. The 60-day stockpile of PPE will be maintained in a separate and designated location within the facility. The local office of emergency management and New York State will be contacted should there be a need for any critical items. 

Memorandums of agreement will be established with key dietary vendors that will send pre-determined orders once activated by a telephone call or email. 

The facility’s has a contracted pharmacy vendor for the supply and management of an onsite pharmacy with national procuring and sourcing power. The contracted pharmacy service works with wholesalers and drug manufacturers to establish primary and contingency plans to address any anticipated medication shortages and pursues a variety of partnerships to purchase in-demand drugs during an escalating crisis (i.e. local hospitals). A 96 hour supply of formulary medications are maintained at the facility for the current census of residents. 

Staff Testing: 

An employee hotline, manned by clinical staff, is utilized for staff to ask questions regarding pandemic exposure or possible exposure, arrange for testing and follow up with ill staff including clearance to return to work based on CDC/DOH regulations. 

Staff testing will be conducted as directed in the New York State Executive Order and/or by the New York State Department of Health. Based on CDC and/or DOH guidelines, asymptomatic staff can make arrangements to be tested at the facility or by an outside provider. For example, indications for testing asymptomatic staff may include periodic testing based on DOH and/or U.S. Department of Health & Human Services (HHS) regulations, those who are returning from a state with significant community spread of COVID-19 and who have been in that state for longer than 24 hours within the past 14 days; staff who had close contact with a person confirmed or suspected to have COVID-19 in the past 14 days; or staff returning to work after a prolonged leave of absence (i.e., maternity leave, workers comp, sick leave, family medical leave or general leave of absence). Helen Hayes Hospital Resident Health Care Facility and Transitional Care Unit Pandemic Emergency Plan 

Staff who are experiencing symptoms suspicious for the pandemic disease call the facility’s hotline to obtain assistance in scheduling an appointment at an off-campus testing site that the facility has made arrangements with or obtain a prescription for testing at a location of their choice. 

Staff related illnesses/absences due to a pandemic are monitored and tracked. Utilization of employee leave accruals will be monitored and based on the New York State Executive Order or as per New York State Department of Health regulations. The facility will adhere to the New York State Department of Health’s directive regarding staff who are returning to work post exposure or infection. 

Communication Plan: 

A Pandemic Communication Plan has been developed and will be reviewed and revised as applicable. 

Staff from Administration, Licensed Nursing Home Administrator, Medical Staff, Nursing Staff and Case Management has developed external notification procedures for the authorized family members and guardians of the residents to keep them apprised of the facility’s current pandemic status. 

Residents, relatives and friends will be provided with an informational document describing the infectious disease event. The residents and their families are notified if the residents or employees develop new disease. 

Daily updates will be provided by nursing staff to authorized family members and guardians of residents infected by a pandemic-related infection. If there is a significant change in a resident’s condition, medical staff will provide this update. Both will use the authorized person’s preferred manner of communication. 

The residents, authorized family members and guardians of all residents 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 by email or telephone or by such other means as may be selected by each authorized family member or guardian by the Case Management staff. 

At no cost, the facility will provide daily alternative communication means between the resident and family members and guardians (e.g., video-conference applications on cell phones or tablets). 

In accordance with all applicable State and federal laws and regulations, to preserve a resident’s place in a residential health care facility if such resident is hospitalized, the resident shall be readmitted to the facility upon the first availability of a bed and after it is determined that the resident meets the criteria for services provided by the facility. The resident and resident representative will be informed of the bed hold and return policy verbally and in writing at the time of admission and at the time the resident is discharged to another facility. 

An up-to-date hospital-wide emergency staff contact list is maintained and updated as applicable. The Emergency Notification System for Helen Hayes Hospital staff through will also be utilized for notification purposes. Helen Hayes Hospital Resident Health Care Facility and Transitional Care Unit Pandemic Emergency Plan 

Recovery / Return to Normal: 

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