Outbreak Plan

Purpose

To develop a comprehensive response plan to address a community-wide infectious disease outbreak such as pandemic influenza and/or Covid-19 in order to protect residents, families, and staff from harm resulting from exposure to an emergent infectious disease while in the facility.

General Preparedness

This document will be used as a guide and will be modified according to local, state and federal health authority mandates at the time of an event. Local, state and federal agencies will be the source of latest information and provide the most up-to-date guidance on prevention, case definition, surveillance, treatment, and the facility’s response related to the specific EID.

This outbreak plan will build on the existing Infection Prevention and Control Program; communication to residents, families and staff; general facility control measures; education; reporting; isolation and cohorting; management of admissions, transfers and readmissions; and staff management.

Clinical leadership will be vigilant and stay informed about EID around the world. They will keep administrative leadership briefed, as needed, on potential risk of new infections in our geographic location through changes in existing organisms, immigration, tourism and other circumstances.

The facility will develop plans with their vendors for re-supply of food, medications, sanitization supplies, and PPE in the event of disruption to normal business.

The facility will regularly train staff and practice EID response plan through drills and exercises as part of the facility’s emergency preparedness training.

Identification of EID in the Community

Once notified by the local, state, or federal agency that EID is likely to, or already has, spread to the facility’s community, the facility will activate specific surveillance and screening as instructed by NJDOH / CDC.

The facility’s Infection Preventionist (IP) will research specific signs, symptoms, incubation period, route of infection, risk of exposure and recommendations for skilled nursing facility as provided by CDC, OSHA, NJDOH, LDOH.

The facility will review and revise internal policies and procedures, stock up on medications, cleaning agents and personal protective equipment in collaboration with the medical director, infectious disease consultant, administrator, director of nursing, infection preventionist, local and state agencies.

Facility will educate staff on the exposure risk, symptoms, and prevention of the EID. Re-education will be provided on basic infection prevention and control, hand hygiene, cough etiquette, use of PPE, isolation and employee sick leave policy.

Facility will provide residents and families with education about the EID and the facility’s response strategy at a level appropriate to their interest.

Facility will brief contractors on the facility’s policies and procedures related to minimizing exposure risk to residents.

Facility will post signs regarding hand hygiene, cough etiquette, restriction of entry to sick individuals, and other preventive strategies relevant to the route of infection.

To ensure staff and new residents are not at risk for spreading the EID into the facility, screening for exposure risk and signs and symptoms surveillance may be done prior to admission of a new resident or new staff.

Staff screening: Staff will be educated on the facility’s plan to control exposure to the residents. Measures will include: reporting any suspected exposure of EID to the supervisor/IP and possible exclusion from work; self-screening of symptoms prior to start of shift; prohibiting staff from reporting to work when sick in compliance with the facility’s Sick Leave Policy.

Self-isolation: In the event there is confirmed case of EID in the community, the facility may consider closing the facility to new admissions, limiting / restricting visitors based on the advice of LDOH.

Environmental Cleaning: Facility will follow current CDC guidelines for environmental cleaning specific for the EID in addition to routine cleaning during the duration of the threat.

Engineering control: Facility will utilize private rooms, convert semi-private rooms to private rooms, install plastic barriers, dividers, sanitation stations, disposal receptacles for waste and PPE as recommended by local, state and federal agencies.

Suspected case of EID in the facility

The facility will:

Place any resident who exhibits symptoms of EID in an isolation room and follow appropriate transmission-based precaution.

Notify local department of health.

Under guidance of local health authority, arrange a transfer of suspected infectious person to the appropriate hospital as soon as possible. Communication of suspicion will be made between transportation personnel and receiving facility.

Keep the numbers of staff entering the isolation room to a minimum. Allow only trained staff to enter the room and utilize the appropriate PPE.

Ask the isolated person to wear mask when staff is in the room. Provide care at the level necessary to address the essential needs of the isolated individual.

Conduct controlled activities such as management of infectious waste, terminal cleaning of isolation room, contact tracing of exposed individuals, surveillance, monitoring through a line listing of additional cases in collaboration with the LDOH.

Implement isolation protocol in the facility such as: implementation of transmission-based precaution, cohorting, cancellation of communal dining and group activities, visitation restriction, staff screening, universal source control as other activities outlined in the infection control and prevention plan and/or recommendations by local, state and federal agencies.

Activate quarantine intervention for residents and/or staff with suspected exposure as directed by local and state health agency.

Employer Consideration 

Management will consider OSHA, CMS, state licensure, Equal Employment Opportunity Commission (EEOC), American Disability Act (ADA) and other state and federal law in determining the precautions that will be taken to protect its residents and employees.  Recognizing that protecting its residents and its employees is of paramount concern.

Management will take into consideration: the degree of frailty of residents in the facility; likelihood of infectious disease being transmitted to residents and employees; method of spread of the disease; precautions which can be taken to prevent the spread of the infectious disease; other relevant factors.

Management will apply whatever action is taken uniformly to all staff in like circumstances.

Management will not consider race, gender, marital status, country of origin unless they are documented relevant to the spread of the disease.

Management will permit employees to return to work when criteria is met (Refer to P&P on sick leave).

Employees who refuse at any time to take the precautions set out in this and other sections of this policy may be subject to disciple including termination. 

Outbreak Plan Specific for Covid-19

Communication

Report any confirmed or suspected outbreak to Middlesex County Local Health Department.

Facility will communicate and coordinate with NJDOH, Middlesex County DOH, Middlesex OEM, NJHA during EID such as Covid-19 outbreak, Monroe Township Office of Emergency Management.

Facility will notify resident’s representative and staff through mass text messaging, website posting, and/or  mailing of letters by 5pm the next calendar day following the subsequent occurrence of either: each time a single confirmed infection of COVID-19 is identified or whenever three or more residents or staff members with new-onset of respiratory symptoms occur within 72 hours of each other.

Facility will notify residents using the in-house television system by 5pm the next calendar day following the subsequent occurrence of either: each time a single confirmed infection of COVID-19 is identified or whenever three or more residents or staff members with a new-onset of respiratory symptoms occur within 72 hours of each other.

Facility will communicate to residents, resident’s representative and staff information on mitigating actions implemented by the facility to prevent or reduce the risk of transmission and alterations in normal facility function through website posting, mailing of letters and/or announcements on our in-house television system.

Facility will provide cumulative updates for residents, their representatives and families of those residing in the facility at least weekly through website posting, mailing of letters and/or announcements on our in-house television system.

Facility will provide virtual communication (phone, video calls, face time) with residents, families and resident’s representative, in the event of visitation restriction due to an outbreak of infectious disease or in the event of an emergency. (Refer P&P for Virtual Communication).

The facility will coordinate with the transport company if a presumptive or confirmed COVID-19 is going to be transported. A face mask will be provided to the resident for transport to protect the transport staff and receiving facility staff.

The facility physician will coordinate with the receiving facility’s physician to ensure report is accurately communicated and precaution is in place.

Reporting

Complete line listing for residents / staff.

Submit line listing to Middlesex DOH per instruction.

Facility will regularly evaluate personal protective equipment (PPE) and report level to corresponding agency: Office of Emergency Management /Local DOH/ NJDOH/ CDC National Healthcare Safety Network (NHSN) Covid-19 Module.

Facility will continue to report testing data through the New Jersey Hospital Association (NJHA); CDC National Healthcare Safety Network (NHSN) Covid-19 Module.

Facility will complete NJDOH Novisurvey Questionnaire for outbreak updates.

Admission, Transfer and Readmission 

Facility will designate one wing in Nassau Unit as the cohort for the 14-day quarantine residents who are new admissions and readmissions in the facility.

Facility will close any affected unit to new admissions except as needed to cohort individuals and staff.

Facility will consider closing to new admissions if the facility is unable to appropriately cohort. This does not include readmission back to the facility.

When transferring resident to another facility / hospital, transporting company will be informed of the Transmission Based Precaution in place as well the as receiving facility.

New admissions and readmission will be monitored for signs of COVID-19 for 14 days and will be cared for by staff using COVID-19 PPE (N95, eye protection, gloves and gown). They will be placed in private rooms (if available). If feasible, a cohort will be created for this population.

Infection Prevention and Control Measures

The facility will ensure sufficient supply of hand hygiene resources in the facility.

The facility will educate staff on infection prevention practices, control measures for COVID-19.

The facility will implement universal source control by providing facemasks to all persons in the facility.  As an alternative, in the event of supply shortage, a cloth mask will be provided for staff who do not provide direct resident care.

The facility will restrict visitors and non-essential healthcare personnel, except in certain compassionate-care situations.

The facility will evaluate all persons entering the facility for signs of COVID-19. Temperature checks will be done at entry point. Temperature checks will be done at the start of each shift for all employees.

The facility will monitor all visitors/vendors/physician for elevated temperature and any signs of respiratory symptoms. The following will also be assessed: history of international travel with 14 days, history of exposure to a presumptive or positive COVID-19. Visitors will be screened for any respiratory symptoms and/or Covid-19 symptoms, travel within 14 days from restricted states; exposure to Covid-19 individuals will not be permitted to enter the facility at any time.

Documentation of visitors, vendors, and transport attendants will be kept on file for a minimum of 30 days.

Facility will require visitors who are cleared to enter the facility to perform hand hygiene and use of facemask and restrict visitation to resident’s room.

Signage for visitation, cough etiquette and hand hygiene will be posted in several locations within the facility.

Visitation restriction will be communicated through mass letters, telephone calls and posting of signage. (Refer to Policy and Procedure on Communication)

The facility will facilitate and provide outdoor visitation for our residents per appointment. (Refer to Policy & Procedure for Outdoor Visitation)

Active screening for residents for fever and other COVID-19 symptoms will be performed on every shift.

Any supply delivery will be dropped off by the loading dock and/or at a designated area by the reception.

Alcohol-based hand sanitizers for hand hygiene will be provided in the hallways and on medication carts, based on supply availability.

Necessary PPE will be made available outside the unit doors for easy access to the staff.

Facility will provide EPA disinfectants to allow for frequent cleaning of high touched surfaces and shared resident equipment.

Facility will suspend communal dining and all group activities.

Residents will be encouraged to remain in their rooms. If the resident leaves their room, they should wear cloth face covering or face mask; perform hand hygiene, limit movement in the facility and perform social distancing.

Waste receptacles will be provided for PPE.

The facility will implement Standard and Transmission-Based Precaution including use of a N95 mask.

Signs will be posted for directions proper PPE use in residents on Transmission Based Precaution.

Facility will stockpile PPE (gloves, gown, surgical mask, respirator, face shield / goggles) to be used specifically only in the event of an outbreak.

The facility will engage NJDOH, LDOH, OEM, NJHA as a contingency plan when it anticipates experiencing supply shortages.

The facility will promote the use of telemedicine to reduce Covid-19 exposure to staff and residents.

The facility will use dedicated equipment in isolation rooms. If not possible, all equipment will be cleaned and disinfected using the EPA-registered disinfectant before use with another resident within the cohort.

The facility will conduct routine cleaning and disinfection of high-touch surfaces and shared medical equipment using EPA-registered disinfectant.

The facility will increase frequency of routine cleaning and disinfection.

The facility will prioritize rounding in a “well-to-ill’ staff flow to minimize cross-contamination.

The facility will establish testing capacity to identify SARS-CoV2 through Princeton Medical Center Laboratory for testing and to provide appropriate specimen collection materials (refer to policy and procedure on testing).

Resident Management / Cohorting 

Facility will create 4 cohort groups: COVID-19 Positive; COVID-19 Negative, Exposed; COVID-19 Negative, Not Exposed; New or Re-admission. (Refer to Policy & Procedure on Cohorting).

Facility will implement cohorting plan that allows for separation of residents, dedicating staff and medical equipment to each of these cohorts and allowing necessary space to do so at the onset of an outbreak.

In the event staffing cannot be designated specifically in the COVID-19 unit, staff will work from clean unit to COVID unit.  Staff will cluster work load from clean resident to COVID residents. (well to ill staff flow)

Staff will use COVID-19 recommended PPE: consisting of a  respirator, eye shield and gloves when entering resident rooms.

Laboratory confirmed COVID-19 positive residents will be relocated to designated cohort, with doors closed. Private rooms will be provided if feasible.  Cohorting with another COVID-19 resident maybe done when a private room is not possible.

A person under investigation will not be moved to COVID-19 cohort until results are confirmed.

Roommates of COVID-19 residents are considered exposed and should not share a room with others unless they have tested negative and has been asymptomatic for 14 days from last exposure.

Facility will adhere to the CDC guideline for the discontinuation of Transmission-Based Precaution.

Education

The facility will continue to provide education, training and updates to its staff, residents and family members to help them understand the implications of, and basic prevention and control measures for, COVID-19.

Staff Management

All residents will be provided a mask and instructed to cover their nose and mouth when around others, as tolerated.

The facility will mandate use of universal facemask (source control) for staff while in the facility in addition to active screening of asymptomatic staff.

Staff will be screened by logging their temperature and respiratory symptom checklist at the start of their shift.

Any staff member exhibiting symptoms consistent with COVID-19 will be asked to put on a mask and leave the facility.  Such staff will require clearance from IP before returning to work.

The facility will identify staff that maybe at higher risk for severe COVID-19 and attempt to assign this staff to unaffected units.

The facility will educate and reinforce sick leave policies, including not reporting to work when sick.

The facility will assess staff competency on infection prevention and control measure including putting on and removing PPE.

The facility will conserve use of PPE using CDC guidance for PPE contingency strategies.

The facility has a documented staffing contingency in the event of a staffing shortage brought about by a new outbreak of COVID-19 or any other infectious disease (refer to P&P on Staffing During an Emergency).