COVID-19

OUTBREAK RESPONSE PLAN – Infection Control
POLICY: OUTBREAK PLAN
DEPT:
Clinical Operations
LAST REVISED:
10/2020

PURPOSE:
To create a constant state of readiness; prepare for challenges through the development of an adequate Outbreak Plan (the Plan) that can be integrated with external agencies; and to educate and respond effectively. The Plan will address prevention, mitigation, response and recovery from an outbreak; to lessen the impact should an outbreak occur.
GUIDELINES:
1. If an outbreak begins in another country, heighten surveillance for outbreak and prepare to activate facility plan, as necessary.
2. If an outbreak begins in or enters the United States, activate plan, identify and isolate all potential residents with the virus , implement infection control practices to prevent transmission, ensure rapid and frequent communication within facility and between healthcare facilities and health departments, implement surge-capacity plan to sustain healthcare delivery.
DEFINITIONS:
Infectious diseases
• New infections resulting from changes or evolution of existing organisms
• Known infections spreading to new geographic areas or populations
• Previously unrecognized infections appearing in areas undergoing ecologic transformation
• Old infections reemerging as a result of antimicrobial resistance in known agents or breakdowns in public health measures
Examples of which are ZIKA virus, Ebola Virus, Avian Influenza (Bird Flu), NoroVirus, H1N1 Influenza Virus (Swine Flu), Chikungunya Virus, and SARS-CoV-2 (Corona Virus/COVID-19)
Isolation – Separation of an individual or group who is reasonably suspected to be infected with a communicable disease from those who are not infected to prevent the spread of the disease.
Quarantine – Separation of an individual or group reasonably suspected to have been exposed to a communicable disease but who is not yet ill (displaying signs and symptoms) from those who have not been so exposed to prevent the spread of the disease.
GENERAL PREPAREDNESS FOR INFECTIOUS DISEASE (ID) OUTBREAK:
• The facility’s Emergency Preparedness Plan will include a response plan for a community-wide infectious disease outbreak such as the COVID-19 outbreak. This plan will:
o build on the workplace practices described in the infection prevention and control policies
o include administrative controls (screening, isolation, visitor policies and employee absentee plans
o address environmental controls (isolation rooms, sanitation stations, and special areas for contaminated wastes)
o Address human resource issues such as employee leave
• The facility’s Infection Control Preventionist (ICP) will be vigilant and stay informed about IDs around the world. The ICP will keep administrative leadership briefed as needed on potential risks of new infections in their geographic location through the changes to existing organisms and/or immigration, tourism, or other circumstances.
• As part of the Emergency Preparedness Plan, the facility will maintain adequate emergency stockpile of personal protective equipment (PPE) including moisture-barrier gowns, face shields, surgical masks, disposable N95 respirators, and gloves; essential cleaning and disinfection supplies so that staff, residents and visitors can adhere to recommended infection prevention and control practices.
• The facility will regularly train employees and practice the ID response plan through in-services, drills and/or exercises as part of the facility’s emergency preparedness training.
LOCAL THREAT:
a. Once notified by the public health authorities at either the federal, state and/or local level that the infectious disease is likely to or already has spread to the facility’s community, the facility will activate specific surveillance and screening as instructed by Centers for Disease Control and Prevention (CDC), state agency and/or the local public health authorities.
b. The facility’s ICP will research signs, symptoms, the risks of exposure, and other recommendations as provided by the CDC, and other relevant local, state and federal public health agencies.
c. The facility’s Infection Control Committee (ICC) will serve as the authority for outbreak preparedness and response. The ICC comprises of Director of Nursing, Infection Control Preventionist, Administrator, Director of Environmental Services, and Human Resources Director.
d. Working with advice from the ICC, local and state public health authorities, and others as appropriate, the ICP will review and revise internal policies and procedures, ensure that facility has environmental cleaning agents, and personal protective equipment as indicated by the specific disease threat.
e. Staff will be educated on the exposure risks, symptoms, and prevention of the ID. Placing special emphasis on reviewing the basic infection prevention and control, use of PPE, isolation, and other infection prevention strategies such as hand washing.
f. Post signs regarding hand sanitation and respiratory etiquette and/or other prevention strategies relevant to the route of infection at the entry of the facility along with the instruction that anyone who is sick must not enter the building.
g. To ensure that staff, and/or new residents are not at risk of spreading the ID into the facility, screening for exposure risk and signs and symptoms may be done PRIOR to admission of a new resident and/or allowing new staff persons to report to work.
h. Self-screening – Staff will be educated on the facility’s plan to control exposure to the residents. This plan will be developed with the guidance of public health authorities and may include:
i. Reporting any suspected exposure to the Infectious Disease while off duty to their supervisor.
ii. Precautionary removal of employees who report an actual or suspected exposure to the ID.
iii. Self-screening for symptoms prior to reporting to work.
iv. Prohibiting staff from reporting to work if they are sick until cleared to do so by appropriate medical authorities, and in compliance with appropriate labor laws.
i. Self-isolation – in the event there are confirmed cases of the ID in the local community, the facility may consider closing or limiting the facility to new admissions, and limiting visitors based on the advice of local public health authorities.
j. Environmental cleaning – the facility will follow current CDC guidelines for environmental cleaning specific to the ID in addition to routine cleaning for the duration of the threat.
k. Engineering controls – The facility may utilize appropriate physical plant alterations, if need be, such as use of private rooms for high-risk residents, sanitation stations, and special areas for contaminated wastes as required by local, state, and federal public health authorities.
SUSPECTED CASE IN THE FACILITY:
• Place a resident who exhibits symptoms of the ID in an isolation room, if applicable, and notify local public health authorities.
• Under the guidance of public health authorities, arrange a transfer of the suspected infectious person to the appropriate acute care center via emergency medical services as soon as possible.
• If the suspected infectious person requires care while awaiting transfer, follow facility’s policies for isolation procedures, including all recommended PPE for staff at risk of exposure.
• Assign dedicated staff to enter the room of the isolated person as feasible. Ideally, only specially trained staff and prepared (i.e. vaccinated, medically cleared) will enter the isolation room.
• Provide all assigned staff additional training and supervision in the mode of transmission of this ID, and the use of the appropriate PPE.
• Ask the isolated person to wear a facemask while staff is in the room. Provide care at the level necessary to address essential needs of the isolated individual unless it is advised otherwise by public health authorities.
• Conduct control activities such as management of infectious wastes when required to do so by local, state, and federal public health authorities, terminal cleaning of the isolation room, and reporting to the DOH for contact tracing of exposed individuals, as well as monitoring for additional cases under the guidance of local health authorities, and in keeping with guidance from the CDC.
• Implement the isolation protocol in the facility, namely, isolation rooms, cohorting, cancelation of group activities and social dining, and/or as recommended by local, state, or federal public health authorities.
• Activate quarantine interventions for residents and staff with suspected exposure as directed by local and state public health authorities, and in keeping with guidance from the CDC.
FACILITY OUTBREAK:
1. The Infection Control Preventionist (ICP) and/or the Infection Control Committee (ICC) assist with decision-making during an outbreak as well as will direct the facility’s planning and response efforts.
2. The ICP and/or ICC should plan to remain active throughout the outbreak period, which could be several weeks or months.
3. Planning for an outbreak should consider concurrent public health, community, and healthcare planning efforts at the local, state and regional levels.
4. The ICP shall serve as the leader in the surveillance for:
 the type of infectious disease outbreak, to include mechanisms for monitoring indications for early cases of outbreak
 mechanisms for tracking facility admissions and discharges of suspected or laboratory-confirmed cases of the specific infectious disease outbreak in residents to support local public health personnel in monitoring the progress and impact of the outbreak
 assess bed capacity and staffing needs, and detect a resurgence in cases that might follow the first wave of cases
 updated information on the types of data that should be reported to the state agency and/or local health departments (e.g., admission; discharges/deaths; resident characteristics such as age, underlying disease, and secondary complications;
 illnesses in healthcare personnel and plans for how this data will be collected during an outbreak
 criteria for distinguishing the type of outbreak from other respiratory diseases.
6. The ICP/ICC/designee will provide the facility’s respiratory surveillance line list for both residents and staff to the state agency and/or the local public health authorities on a daily basis or as directed.
7. The facility’s ICP will periodically review specific Infection Prevention and Control guidance for healthcare facilities caring for residents with suspected or confirmed infectious disease, including COVID-19.
8. The facility’s ICC/ICP will assess the status of infectious disease at the facility, assure proper infection control measures are implemented and ensure monitoring of all residents.
EVALUATION AND MANAGEMENT OF RESIDENTS AND HEALTHCARE PERSONNEL:
 Persons with exposure will be identified.
 HCP must adhere to Standard and Transmission-based Precautions including use of a facemask, and gown, gloves, and eye protection for confirmed and suspected case(s).
o Close contact is defined as being within approximately 6 feet of a positive case for prolonged period of time or having contact with infectious case (e.g., being coughed on) – without PPE. Such close contacts who did not wear PPE should be quarantined for 14 days after last exposure.
 Facility conduct active screening of all residents:
• Nursing Staff will monitor residents every shift for symptoms of the ID and any other illness (unless refused by resident). Vital signs should include heart rate, blood pressure, temperature, pain and pulse oximetry. The Nursing staff will inform the residents’ Attending Physician and Responsible Party for any change in their baseline or condition.
 Facility shall screen and log HCP and persons (when applicable) when entering the facility for symptoms of the infectious disease and/or as needed.
• Screening will include:
a. Temperature checks including subjective and/or objective fever equal to or greater than 100.4 degrees Fahrenheit or as further restricted by the facility.
b. Completion of questionnaire about symptoms and potential exposure which shall include at a minimum:
1. Exhibit signs and symptoms of and infectious disease, including COVID-19, such as fever equal to or greater than 100.4, chills, cough, shortness of breath or difficulty of breathing, sore throat, fatigue, muscle or body aches, headache, new loss of taste or smell, congestion or runny nose, nausea or vomiting, or diarrhea.
2. Has had contact with someone with a confirmed diagnosis of infectious disease, or someone under investigation for the infectious disease, or someone ill with respiratory illness in the last 14 days.
3. In the last 14 days, has returned from a designated state under the 14-day quarantine travel advisory; or
4. Has been diagnosed with the infectious disease and has not yet met the criteria for the discontinuation of isolation per guidance issued by the NJDOH.
 Facility will implement universal use of facemask for all staff as well as recommend it for the residents.
 Stop indoor communal dining and all group activities.
 Encourage residents to remain in their rooms and/or apartments as much as possible/tolerable.
 Residents will be provided with masks (who can tolerate masks) whenever they leave their room, including for procedures outside the facility; if masks are limited or not tolerated or resident refuses to wear mask, resident will be urged and/or provided with a tissue to cover the nose and mouth (and/or with a face shield, when applicable).
 Educate residents and staff regarding the current precautions being taken in the facility and protective actions such as practicing social distancing and performing frequent hand hygiene.
 Post signs regarding hand sanitation and respiratory etiquette and/or other prevention strategies relevant to the route of infection at the entry of the facility along with the instruction that anyone who is sick that must not enter the building.
COHORTING:
Facility will cohort residents as follows:
A. COHORT A – INFECTED RESIDENTS
This cohort consists of both symptomatic and asymptomatic residents who test positive for the infectious virus, including any new or re-admissions known to be positive, who have not met the discontinuation of Transmission-Based Precautions criteria. If feasible, care for positive residents on a separate closed unit. Residents who test positive for COVID-19 virus are known to shed the virus, regardless of symptoms; therefore, all positive residents would be placed in this positive cohort. Alternatively, Residents that have a private room or a private apartment would be isolated in place in their respective private room/apartment.
B. COHORT B –NEGATIVE, (EXPOSED)
This cohort consists of residents who test negative for the virus with an identified exposure to someone who was positive. Exposed individuals should be quarantined for 14 days from last exposure, regardless of test results. Residents who test negative for the virus could be incubating and later test positive. To the best of our ability, facility will separate symptomatic and asymptomatic residents, ideally having one group housed in private rooms. Even though symptomatic negative residents might not be a threat to transmit the infectious disease virus, they still may have another respiratory illness. Asymptomatic residents should be closely monitored for symptom development.
Alternatively, Residents that have a private room or a private apartment would be isolated in place in their respective private room/apartment.
C. COHORT C – NEGATIVE, (NOT EXPOSED)
Facility will dedicate a separate unit/wing residents who test negative for the virus and with no symptoms and are thought to have no known exposures. This cohort will only be created when the facility is relatively certain that residents have been properly isolated all positive and incubating residents and HCP.
Alternatively, in case a widespread facility-wide outbreak, Negative (Not-Exposed) residents that have a private room or a private apartment would be isolated in place in their respective private room/apartment.
D. A resident who shares the same apartment of a Suspected Covid resident or who shares the same room/apartment of an actual Covid Positive resident, shall remain in his/her shared apartment with the Suspected Covid Resident, or respectively, with the actual Covid Positive resident, and shall be monitored for signs and symptoms of the ID as well as be tested for it. This shall be in place even if this resident has a current Negative status.
E. COHORT D – NEW OR RE-ADMISSIONS
This cohort consists of all persons from the community or other healthcare facilities who are newly or readmitted. This cohort serves as an observation area where persons remain for 14 days to monitor for symptoms that may be
compatible with the infectious virus, including COVID-19. Testing at the end of this period could be considered to increase certainty that the person is not infected. Persons positive for the virus who have not met the discontinuation of Transmission-Based Precautions should be placed in Cohort 1 –Positive. Individuals who have cleared Transmission-Based Precautions and it has been more than 3 months after the date of onset or positive viral test (for asymptomatic) or prior infection can go to Cohort 3.
Alternatively, Residents that have a private room or a private apartment would be isolated in place in their respective private room/apartment.
COMMUNICATION:
• Spring Oak Assisted Living will remain in contact with the Camden County Health Department as needed and/or requested to provide situational awareness. These communications include activation, deactivation, suspension/resumption of services, critical resource shortages and hazardous situations.
• Spring Oak will maintain communication with staff, through mass text, phone calls and postings, regarding COVID-19 –related developments, and/or other changes in service.
• Spring Oak will use signage, email, phone messaging, website, and/or social media to provide basic, required information to residents and families. The facility maintains an active email list of all pertinent residents and legal next-of-kin, which shall be utilized for this purpose.
• Administration will monitor the NJ Health Alert Network, CDC website and the NJ Department of Health website for updated information on urgent and emergent public health situations.
• Spring Oak will report all required metrics to local health departments, NJ Dept of Health, and CDC NHSN, in accordance with NJ Dept of Health directives.
In the event that any Resident or Power-of-Attorney should have a pressing concern related to COVID-19, please contact the Facility Executive Director at the facility phone number (732) 905-2055 or email [email protected]
EDUCATION AND TRAINING:
• Facility will provide Staff education regarding the Outbreak as follows:
1. General topics for staff education will include:
• Prevention and control of the infectious disease which includes practicing social distancing and performing frequent hand hygiene.
• Implications of the disease
• Identify signs and symptoms of infectious disease that can result to an Outbreak.
• Infection control strategies for the control of the infectious disease, including respiratory hygiene/cough etiquette, hand hygiene, standard precautions, droplet precautions, and, as appropriate, proper donning, doffing and discarding of Personal Protective Equipment (PPE).
2. Specific topics for staff education should include:
• Care infected residents, including how and where infected residents will be cohorted.
• Self-screening of symptoms prior to reporting to work.
• Reporting any suspected exposure to the Infectious Disease while off duty to their supervisor.
• Communication methods with families such as facility website, emails, and/or phone calls.
• Restricting visitors
3. ICP/Designee will provide training to staff, as well as recommended infection prevention and control practices.
FACILITY ACCESS:
• Facility shall screen and log staff and persons (when applicable) upon entering the facility.
• Facility shall follow federal and state directives in regards to restricting or allowing entry in the facility (e.g. not requiring EMS personnel any additional screening).
• Entry of non-essential personnel and volunteers is prohibited.
• Pursuant to federal and state directives, in the event that visitation in limited situations such as End-of-life, Compassionate Care and Essential Caregiver are allowed:
 Facility will ensure that all visits are conducted as safely as possible and require infection control practices, hand hygiene and appropriate PPE in accordance with CDC guidance.
 No more than two (2) visitors are permitted at one time per resident.
 All visits are by appointments (when applicable) only to limit the number of visitors inside the building at the same time.
 Upon screening, the facility shall prohibit entry into the building for those who meet the one or more of the following criteria:
o Exhibit signs and symptoms of and infectious disease, including COVID-19, such as fever equal to or greater than 100.4, chills, cough, shortness of breath or difficulty of breathing, sore throat, fatigue, muscle or body aches, headache, new loss of taste or smell, congestion or runny nose, nausea or vomiting, or diarrhea.
o Has had contact with someone with a confirmed diagnosis of infectious disease, or someone under investigation for the infectious disease, or someone ill with respiratory illness in the last 14 days.
o In the last 14 days, has returned from a designated state under the 14-day quarantine travel advisory; or
o Has been diagnosed with the infectious disease and has not yet met the criteria for the discontinuation of isolation per guidance issued by the NJDOH.
If after undergoing screening, the visitor is permitted to enter the building, the facility shall:
 Require the visitor to wear a cloth face covering or a facemask.
 Limit the visitor’s movement within the facility to the resident’s room or designated space (e.g. reduce walking the halls, avoid going to dining room, etc.)
EMERGENCY STAFFING CONTINGENCY:
In the event of an emergency or when staffing shortages are anticipated, the Administrator or designee will make the decision to utilize emergency staffing strategies as necessary to provide for care and treatment of residents.
1. In case of an anticipated or an emergency staffing shortage, administrator or designee will communicate with local healthcare coalitions, federal, state, and local public health partners.
2. Employees in the facility will be notified of the decision to utilize emergency staffing strategies.
3. The facility will adjust staff schedules, hiring additional HCP, and rotating HCP to positions that support patient care activities.
4. Cancel all non-essential procedures and visits.
5. Attempt to address social factors that might prevent HCP from reporting to work such as transportation or housing if HCP live with vulnerable individuals.
6. Identify additional HCP to work in the facility. Be aware of state-specific emergency waivers or changes to licensure requirements or renewals for select categories of HCP.
7. Request that HCP postpone elective time off from work.
8. Administrator or designee will contact staffing agencies to secure staff.
9. Remove tasks from the nursing department that does not need to be completed by a CNA or nurse including but not limited to passing out water, answering call bells, passing out snacks and designate these tasks to alternate employees such as recreation or housekeeping.
10. Unit Clerks will assist on the unit as well as other staff within the scope of their practice.
11. Nursing Administration (DON, Supervisors) may need to work on the units as needed.
12. Social Services/Activities/Concierge and Administration to assist on the units as necessary i.e. answering phone calls, call bells, passing out meal trays etc.
13. Dietary may utilize paper goods in order to free staff to assist in other areas.
14. Utilizing agency staff as necessary.
15. Utilizing emergency waivers or changes to licensure requirements as appropriate.
In addition, the following measures will be put in place:
• Facility will contract with healthcare recruiters for low level staff.
• Facility will reach out to schools and colleges for new CNA and nurse graduates.
• Monetary compensation will be in effect as necessary.
• All department heads can be mandated to work 7 days a week for the duration of the crisis.
• Licensed aids and nurses in other departments (i.e. admissions, liaisons etc.) will be mandated to work on the floors.
• Aggressive recruiting and ads will be placed to attract new staff.
• Any additional measures needed will be considered on a day to day basis.
Crisis capacity strategies include:
a. Implementing regional plans to transfer patients with infectious disease, including COVID-19 to alternate care sites with adequate staffing.
b. Implementing criteria to allow HCP with suspected or confirmed infectious disease, including COVID-19 who have not met Return to Work Criteria to work, in accordance with CDC guidelines.
RETURN-TO-WORK:
Following CDC guidelines, the employee who has a confirmed positive for Infectious Disease, including COVID-19, may return to work using one of the strategies:
1. SYMPTOM-BASED STRATEGY:
a. SYMPTOMATIC:
 For HCP with severe to critical illness or who are severely immunocompromised:
 At least 20 days have passed since first symptom appeared.
 At least 24 hours have passed since last fever without the use of fever-reducing medications
 AND – Symptoms (e.g. cough, shortness of breath) have improved.
 For HCP with mild to moderate illness who are not severely immunocompromised:
 At least 10 days have passed since first symptom appeared.
 At least 24 hours have passed since last fever without the use of fever-reducing medications
 AND – Symptoms (e.g. cough, shortness of breath) have improved.
b. ASYMPTOMATIC:
 HCP who are severely immunocomprised but were asymptomatic throughout their infection may return to work when at least 20 days have passed since the date of their positive viral diagnostic test.
 HCP who are not severely immunocompromised and were asymptomatic throughout their infection may return to work when at least 10 days have passed since the date of their positive viral diagnostic test.
2. TEST BASED STRATEGY: (Only for rare situations)
a. SYMPTOMATIC:
• Resolution of fever without the use of fever-reducing medications AND,
• Improvement in symptoms (e.g. cough, shortness of breath), AND,
• Negative results of an FDA Emergency Use Authorized molecular assay from at least two consecutive respiratory specimens collected ≥24 hours apart (total of two negative specimens).
*Test must be FDA Use Authorized molecular Assay approved.
b. ASYMPTOMATIC:
• Negative results of an FDA Emergency Use Authorized molecular assay from at least two consecutive respiratory specimens collected ≥24 hours apart (total of two negative specimens).
*All criteria must be met before HCP can return to work under this option.
CONSUMABLE AND DURABLE SUPPLIES:
• Facility will maintain PPE in stock (and/or at it’s regional headquarters) as mandated by state and federal authorities.
• Re-assigning non-essential staff to support other facility services or placing them on administrative leave; cohort staff caring for residents afflicted with the virus.
• Assign staff recovering from the infectious disease to care for infected residents.
• Staff who have signs and symptoms of the infectious disease must notify their supervisor and not report to work.
• Facility will report the number of positive and suspected cases, resident bed and census, staffing shortages, status of PPE and hand hygiene supplies, to the local and state health departments as directed.
• Facility will coordinate with local and state health departments about access to the national stockpile during an emergency.
ENVIRONMENTAL CLEANING AND DISINFECTION:
• Housekeeping Department will increase the frequency of routine cleaning and disinfection of frequently touched surfaces using products that have EPA-approving emerging viral pathogens claims that have demonstrated effectiveness against viruses similar to COVID-19 on surfaces.
• Adhere to internal environmental cleaning protocols to ensure appropriate measures are being taken to clean and disinfect throughout the facility.
• Appropriate staff personnel shall adhere to infection control protocols when handling laundry.
TESTING:
 Facility has a contracted laboratory that will ensure prioritization of test results and testing capacity for repeat facility-wide testing of residents and staff. Facility will contract with other laboratories or vendors if needed to meet testing requirements.
 Facility will test all residents and staff according to CDC and NJDOH guidelines.
 Facility will perform continued testing of residents and staff whenever required according to CDC and NJDOH guidance.
 Facility will report testing data to the state and/or local health department and other agencies as directed.
Please note this document is intended to help guide decisions in consultation with the clinical team and facility specific resources. We are experiencing a rapidly evolving situation and as more guidance and resources become available, the Plan will be adjusted and revised as needed. To ensure you have the most updated Plan, please reach out to the facility.