Split Rock Rehabilitation & Healthcare Center

Pandemic Emergency Plan

Comprehensive Emergency Management Plan Pandemic Emergency Plan Annex

Revised September 2020

TABLE OF CONTENTS

I. Introduction

II. Purpose

III. Risk Assessment

IV. Communication Plan/Checklist

V. Infection Protection Plans for Staff, Residents and Families

A. Overview

B. Readmission/Bed Hold

C. Overall Strategies to Prevent Transmission/Response to Pandemic (Response Checklist)

D. Personal Protective Equipment (PPE)

VI. Other PEP Considerations Checklist (Applicability May Vary Based on the Nature of the Pandemic)

VII. Communicable Disease Reporting to Government Agencies

VIII. Recovery Checklist

I. Introduction

Although remarkable advances have been made in science and medicine during the past century, we are constantly reminded that we live a universe of microbes that are forever changing and adapting themselves to the human host and the defenses that humans create. While science has developed highly effective vaccines and treatments for many infectious diseases that threaten public health, new, potential threats, such as the coronavirus have the potential to spread across the globe.

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.

A pandemic is an event in which an infectious disease spreads across several countries and affects a large number of people. It has the potential to cause more death and illness than any other public health threat. This Pandemic Emergency Plan (PEP) Annex has been reviewed and endorsed by senior leadership for use at The Wayne Center for Nursing & Rehabilitation (Wayne). The plan is a component of Wayne’s Comprehensive Emergency Management Plan (CEMP), and outlines Wayne’s strategy in preparing for, responding to, and recovering from a pandemic.

II. Purpose

The purpose of the CEMP is to identify Wayne’s overarching policies, authorities and response organizational structure that will be implemented in an emergency or disaster situation that warrants a Wayne response. In addition, the CEMP identifies the lines of coordination and the centralized coordination of resources that will be utilized in directing the Wayne’s resources and capabilities in responding to and recovering from a disaster. Moreover, the CEMP serves as the foundational framework for the Wayne’s response levels and serves as the operational basis on which other functional and hazard-specific annexes will build upon.

To protect the well-being of residents, staff, and visitors, an all-hazards approach has been used to develop the CEMP, which now includes considerations necessary to satisfy the requirements for a PEP. The CEMP has been adjusted to meet the needs of the PEP. Relevant sections of the PEP will be posted on the Wayne website for public viewing and will be provided immediately upon request. The CEMP is informed by the conduct of facility-based and community-based risk assessments and pre- disaster collaboration with Centers for Medicare & Services (CMS), New York State Department of Health (NYSDOH), New York City Office of Emergency Management, New York Police Department, New York Fire Department and others.

The purpose of the PEP Annex is to ensure that the strategic and broad-based nature of the Wayne CEMP is more defined to allow the Wayne to adequately prepare for, respond to, and recover from a pandemic.

As part of the CEMP, the PEP Annex is reviewed and updated as needed at least annually.

III. Risk Assessment

Wayne conducts an annual risk assessment to identify which natural and man-made hazards pose the greatest risk to the facility, i.e., human and economic losses based on the vulnerability of people, buildings, and infrastructure. This risk information serves as the foundation for the plan—including associated policies, procedures, and preparedness activities. Wayne conducted a facility-specific risk assessment in December 2019 and determined Infectious Diseases/Pandemic are among the hazards that may affect the facility’s ability to maintain operations before, during, and after an incident.

IV. Communication Plan/Checklist

Wayne maintains external notification procedures directed toward authorized family members and guardians of residents, that includes at minimum:

V. Infection Protection Plans for Staff, Residents and Families

A. Overview

Wayne maintains an infection control program in accordance with applicable Wayne and federal laws and regulations, including but not limited to 10 NYCRR 415.19, 415.3(i)(3)(iii) and 415.26(i); and 42 CFR 483.15(e). The program is designed to provide a safe, sanitary, and comfortable environment in which residents reside and to help prevent the development and transmission of disease and infection, in accordance with guidance/directives from the Centers for Disease Control (CDC) and regulatory agencies, including the New York State Department of Health (NYSDOH). This policy may change based on changing guidance/directives from these agencies.

B. Readmission/Bed Hold

Protocols for readmission to Wayne for hospitalized residents after treatment are established in accordance with all applicable laws and regulations and are structured to minimize risk of exposure to residents, families and staff. Screening protocols and readmission criteria vary depending on various factors, including the nature of the communicable disease, its modes of transmission, comorbidities, ability to safely cohort or isolate, etc. The interdisciplinary team, including the Infection Preventionist, Director of Nursing and Medical Director are involved in establishing protocols for readmission.

Residents who are hospitalized will have their beds preserved at Wayne 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).

C. Overall Strategies to Prevent Transmission/Response to Pandemic (Response Checklist)

D. Personal Protective Equipment (PPE)

Wayne maintains or contracts to have at least a two-month (60-day) supply of PPE. The supply needs are based on facility census, not capacity. To determine supply needs during a pandemic episode, Wayne bases such need on NYSDOH existing guidance and regulations or other tools such as the Center for Disease Control and Prevention (CDC) PPE burn rate calculator.

All efforts are made to be cognizant of experience with prior pandemic response and adopt protocols outlined in guidance that are specific to the pathogen and illness circulating at the time of the pandemic, and plan to handle worst case scenarios without implementing shortage or other mitigation efforts.

Calculations of PPE supplies address all personal protective equipment necessary for both residents and staff to continue to provide services and supports to residents, current guidance on various supplies and strategies from the CDC. Supplies to be maintained include, but are not limited to: N95 respirators, face shield, eye protection, gowns/isolation gowns, gloves, masks, and sanitizer and disinfectants in accordance with current EPA Guidance.

VI. Other PEP Considerations Checklist (Applicability May Vary Based on the Nature of the Pandemic)

VII. Communicable Disease Reporting to Government Agencies

Wayne recognizes the importance of reporting communicable disease data, as part of its efforts to protect public health and ensure the safety of its residents. Such reporting contributes to the detection of intra-facility outbreaks, geographic trends, and the identification of emerging infectious diseases. The collection of outbreak data enables the NYSDOH to inform health care facilities of potential risks and preventive actions.

Any outbreak or significant increase in nosocomial infections above the norm or baseline in nursing home residents or employees is reported to NYSDOH, either electronically via the Nosocomial Outbreak Reporting Application (NORA) on the NYSDOH Health Commerce System (HCS), or via fax of an Infection Control Nosocomial Report Form (DOH 4018) on the DOH public website.

Wayne conducts surveillance that is adequate to identify background rates and detect significant increases above those rates. A single case of a reportable communicable disease or any unusual disease (defined as a newly apparent or emerging disease or syndrome that could possibly be caused by a transmissible infectious agent or microbial toxin) is reported to the New York City Department of Health and Mental Hygiene (NYCDHMH). In addition, if the reportable communicable disease is suspected or confirmed to be acquired, it is also reported to the NYSDOH.

Wayne reviews and assure that there is adequate facility staff access to communicable disease reporting tools and other outbreak specific reporting requirements on the HCS, e.g., NORA, HERDS surveys. Resident data is maintained in the electronic medical record. Employee surveillance data is maintained in a centralized database in Nursing. Infection preventionist and nursing leadership to have access to the data.

Reports to the NYCDHMH are submitted within 24 hours of diagnosis. However, some diseases warrant prompt action and should are reported immediately by phone.

VIII. Recovery Checklist

Cathy Rauschendorfer

Director of Social Services

Cathy Rauschendorfer is the Director of the Social Services department at Split Rock.  She joined our team in 2018, bringing with her, 17 years of experience in long term care.  Cathy received her Master’s degree from Fordham University, where she graduated Summa cum laude.  She is a Licensed Social Worker as well as a Licensed Nursing Home Administrator.

Cathy provides supervision and leadership to the Social Work team at Split Rock, as well as, providing support and education for the residents, families and the staff at the facility.  Cathy’s experience has given her a deep appreciation for how the quality of life for those we serve is impacted by the quality of care we provide. Therefore, she is dedicated to providing excellent service to all those that the facility serves.

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Rachel Sampson

Director of Respiratory

Rachel M. Sampson, MPH, RRT is the director of respiratory care services.  She brings to the facility 25 years of experience working with residents in acute and sub-acute facilities who present with varying respiratory illnesses.

Ms. Sampson is passionate about providing quality care to all, and with a team of dedicated respiratory therapists, is always searching for new developments and modalities to utilize for the respiratory population at the facility. The director is often consulted by other professionals @ Spilt Rock for her clinical expertise.

Although respiratory care is her specialty she enjoys interacting with all the residents and can be seen throughout the facility laughing and encouraging the residents to achieve their goals.

Her motto is: Quality care @ all times.

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Soha Alsafadi

Director of Nursing Services

Soha is a creative, dedicated and engaging, highly accomplished healthcare leader professional with a Master's degree in Nursing Administration, along with 30+ years of nursing experience, with the last 13 years being in leadership and management. Expert at building high-performing nursing teams. Energetic, determined, proactive and forward-thinking innovator and imparts a passion for providing high quality and safe patient care whilst demonstrating exceptional professional and clinical excellence. Talented and sought after nursing professional with excellent academic credentials and a proven capacity to work in multi-cultural.

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Dr. Mary Rose

Director of Rehabilitation

Dr. Mary Rose Custodio-Ober has been a Physical therapist in NY since 2004. She received her bachelors from De La Salle University, Philippines and her doctorate from Dominican College, New York. Dr. Ober manages the rehabilitation department of Split Rock Rehabilitation and Health Care Center ensuring a systemic approach to assessing and constructing operational efficiencies to enhance patient care and services.

In her years of service, she has demonstrated great leadership skills, often partaking on patient care, providing knowledge, advice, and counsel. She ensures that her team members feel comfortable and encourages collaboration in creating an interdisciplinary team approach towards patient care. Dr. Ober personifies professionalism in every duty she partakes, demonstrating ethical responsibility and excellence in conflict management to advocate for both rehab personnel and residents.

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Cristobal Castillo F.S.D

Director of Food Services

Cristobal Castillo has 20 plus years’ experience in the food industry and hospitality industry. He has served as a Food Service Director for 13 years at Split Rock Rehabilitation and Healthcare Center. As director of food services, he implements advanced systems to improve food service quality. In addition, he offers nutritious and high-quality cuisines. He upholds high standards of food safety, sanitary conditions, and hospitality practices. Additionally, he works with the recreation team to develop entertaining, captivating, and engaging events for residents and staff morale. He cares deeply about the wellbeing of the residents and strives to win their approval. He is aware of the profound impact that a delicious meal presented beautifully can have on someone's day.

Cristobal grew passion for the food industry at an early age. He took a few classes at Culinary Institute of NY in the early 2000’s. He is SERV safe Certified (QFO) and holds a New York State Mental Health and Hygiene Food Handlers Certificate. He has 20 years of hospital culinary expertise, first as a Sous Chef at Our Lady of Mercy Medical Center and later as a Chef/Purchasing Manager at Montefiore Medical Center.

Father of four children and three grandchildren, Cristobal is a devoted husband. He enjoys going outdoor hiking, swimming in rivers, watching football, baseball, and basketball games, and spending time with his family.

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Christina DePolo

Director Of Recreation Services

Christina joined Split Rock Rehab. & Health Care Center as it’s Activities Director early 2021 with a mission to provide quality of life to her residents.  Over the past year, she had done just that, fulfilling her purpose through engaging, interactive and rewarding one-on-one and group activities for the individuals she serves.  In the capacity of Activities Director, Christina is responsible for the development and coordination of activity programs for the community that reflects the varied interests and needs of the residents and provides them with meaningful and life enriching activities.

Bringing with her over 20 years of professional expertise, Christina understands the value of elevating her residents’ lives through personal engagement and enrichment.  She is aware that activities play a vital role in improving the quality of life in every resident in our community, regardless of their physical, emotional, social or spiritual status is.

Christina is a Certified Activities Director through the National Certification Council For Activity Professionals.  She is a graduate of Fordham University.

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Rebecca Fine MS RDN CDN

Director of Dietary Services

Rebecca earned her Bachelor of Science & her Master of Science in Nutrition
from Brooklyn College.

Rebecca has been working in Long-Term care as a Registered Dietitian for over 20 years.
Her specialties include providing optimum care for high risk patients including residents on a ventilator, providing enteral nutrition, working closely with our hemodialysis team, oncology & has vast experience with residents who exhibit advanced stage dementia. Rebecca has had a lot of success working with the SplitRock team in helping patients upgrade their diet consistencies, in weaning patients off of enteral feeding & ventilators, and improving their quality of life.

Rebecca also works closely with the short-term care & Adult day care population and provides seminars & lectures on nutrition education, giving them relevant tools that they can utilize to improve their nutrition when they are returned back to their home environment.

Rebecca has fun interacting with our residents, often joining in their karaoke jam sessions
and other activities.

Rebecca believes that communication between staff, residents & families is fundamental in achieving the best possible outcome for her patients.

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