Outbreak Response Plan

September 14, 2020

MANUAL: NURSING

FACILITY: ACTORS FUND HOME

DATE: REVISED SEPTEMBER 10, 2020

POLICY: Outbreak Response Plan

POLICY #:            

POLICY

The protocol for isolating and cohorting infected and at risk residents in the event of an outbreak of a contagious disease until the cessation of the outbreak. The plan was done in accordance with the current guidelines from the Centers for Medicare and Medicaid (CMS), Centers for Disease Control (CDC), state and local guidance for infection prevention for the duration of the COVID-19 pandemic. The Outbreak Response Plan was developed based on the requirements outlined in ED 20-026, the Directive for the Resumption of Service in Long Term Care Facilities (LTC).

PURPOSE

Prevention and control of an outbreak of a contagious disease until the cessation of the outbreak.

PROCESS

Core Practices of Infection Prevention

The Infection Control Program is comprehensive in that it addresses detection, prevention and control of infections among residents and staff.

THE MAJOR ACTIVITIES OF THE PROGRAM ARE:

  1. SURVEILLANCE OF INFECTIONS
    There is on-going monitoring for infections among residents and staff and subsequent documentation of infections that occur.  Routine monitoring of residents and staff shall be performed to quickly identify signs of a communicable disease that could develop into an outbreak.
  2. IMPLEMENTATION OF CONTROL MEASURES
    Prevention of spread of infections is accomplished by use of Standard Precautions and other barriers, appropriate treatment, and follow-up, and employee work restrictions for illness.
  3. PREVENTION OF INFECTION
    Staff and resident education is done to focus on risk of infection and practices to decrease risk.  Policies, procedures and aseptic practices are followed by personnel in performing procedures and in disinfection of equipment.  Immunizations are offered, as appropriate to residents and personnel to decrease the incidence of preventable infectious diseases.

DIVISION OF RESPONSIBILITIES FOR INFECTION CONTROL ACTIVITIES

The Actors Fund Home has created an Infection Control Committee which will be ultimately responsible for planning, monitoring, evaluating, investigating, controlling and preventing health-care associated infections (HAIs). The Team will develop a system of care that promotes sound and scientific infection prevention principles and practices. Partnering with the Medical Director, Administrator, Assistant Administrator, DON, and Infection Prevention Nurse (IPN) are Infection, Preventionist Consultant, Lucille Plantemoli and Infectious Disease Doctor, Dr. Ashwin Jathavedam. The Infection Prevention Committee will make rounds and meet on a monthly basis.

INFECTION PREVENTION NURSE

Responsibility is delegated to the Infection Prevention Nurse (IPN) to carry out the daily functions of the Infection Control Program. These functions are described in the IPN job description. The IPN has knowledge and interest in Infection Control.

AUTHORITY

To take immediate and appropriate action to correct any deficiencies relating to infection control that create hazardous conditions.

REPORTING

The IPN prepares infection reports and presents them to the Infection Prevention Committee.  Problems are identified and actions are planned for resolution and presented to the Committee.

RESPIRATORY PROTECTION PROGRAM

The facility will develop and implement a Respiratory Protection Program within nine (9) months that complies with the Occupational Safety and Health Administration (OSHA) respiratory protection standards for employees.  The program will include medical evaluations, training and fit testing.

In order for the facility to meet the requirements of the Executive Directive No. 20-026, the facility will submit to the Department via email to:  LTC.DiseaseOutbreakPlan@doh.nj.gov an Infection Control Employee attestation on facility letterhead from the administrator with the facility name and license number, stating the facility has implemented a respiratory protection program that complies with the OSHA respiratory protection standard for employees.

PERSONAL PROTECTIVE EQUIPMENT (PPE) STOCKPILING/INVENTORY

The facility will have an adequate emergency stockpile of PPE, and essential cleaning and disinfection supplies so that staff, residents and visitors can adhere to recommended infection prevention and control practices.

The facility has essential cleaning and disinfection supplies on hand in the event of a supply chain disruption.

If the facility is forced to use the PPE stockpile due to an emergency, the facility is required to re-stock and resubmit the attestation statement indicating the restocking in accordance with Executive Directive 20-026 to:  LTC.PPEStockpile@doh.nj.gov.

REPORTING TO THE NHSN PROGRAM

The facility is required to report, at minimum twice per week, COVID-19 cases, facility staffing, and supply information to the National Healthcare Safety Network (NHSN) Long Term Care Facility COVID-19 Module:

https://www.cdc.gov/nhsn/ltc/covid19/index/html.

  • Counts of residents and facility personnel with suspected and laboratory positive COVID-19.
  • Counts of suspected and laboratory positive COVID-19 related deaths among residents and staff.
  • Resident beds and census.
  • Staffing shortages.
  • Status of PPE and hand hygiene supplies.

STAFFING STRATEGY

The facility will have no staffing shortages and will not operate under a contingency nor crisis staffing plan.  (Required by NJDOH E.D. 20-026.)  The facility will secure additional staff in the event of a new COVID-19 or other infectious disease outbreak.

COHORTING/RESIDENT PLACEMENT

Room Assignment/Placement:

  1. Private Room preferred.
     
  2. Cohort – When a private room is unavailable, a group of residents who are or are not colonized or infected with the same organism will be confined for their care to one area and to prevent contact with other residents.
     
  3. Placed with an individual where no invasive procedures are performed or use of invasive equipment (e.g., catheters).
     
  4. Use disposable equipment (i.e., stethoscopes, blood pressure cuffs, etc.)
     
  5. A “STOP SIGN” will be placed at the door to alert staff and visitors to see the nurse before entering.
     
  6. Personal Protective Equipment (gown, gloves, hair nets, shoe covers, etc.) are available on the unit.

PPE REQUIREMENTS

GLOVES AND HANDWASHING:

  • Review standard precautions.
  • During care, if gloves contact highly infectious materials (e.g., feces, wound drainage, etc.), change them.  
  • After removing gloves, wash hands with antimicrobial agent for at least 20 – 30 seconds (Refer to Handwashing Policy).

GOWN:

  • Review standard precautions.  Follow PPE Protocol.
  • Wear a gown when you anticipate clothing will be contaminated by the individual or by contact with environmental surfaces or items in the individual’s room.
  • When removing the gown follow PPE Protocol.

MASKS:

  • N95 respirator masks will be used in the facility by staff to reduce the wearer’s exposure to airborne particles, from small particle aerosols to large droplets.

TRANSPORT:

  • If an individual leaves his/her room, ensure that precautions are taken to minimize the risk of transmission of microorganisms (e.g., cover wounds, observe personal hygiene, and wear respiratory masks).

EQUIPMENT:

  • When possible, dedicate the use of non-critical equipment to a single individual.
  • If use of common equipment is unavoidable, thoroughly clean and disinfect in between uses.

TRAINING:

The facility will educate residents, staff, and visitors about COVID-19, including current precautions being taken in the facility, and protective actions. The facility will train and provide staff with all recommended COVID-19 PPE, to the extent PPE is available, and consistent with CDC guidance on optimization of PPE.

TRANSFERS:

  1. The facility shall implement universal source control for visitors and staff in the building.  All residents, whether they have COVID-19 symptoms or not, must practice source control when around others (surgical mask) in accordance with CDC guidance. 
  2. The facility will separate COVID-19 positive and negative residents in accordance with NJDOH guidance.  A resident is considered recovered from COVID-19 only after they have met the criteria for discontinuation of isolation as defined by the NHJDOH and CDC guidance.
  3. The facility will continue to follow current NJDOH orders, guidance and directives on admissions and readmissions.  Facilities may receive residents who were tested prior to admission transfer or shortly thereafter, in accordance with NJDOH guidance.  The facility will take appropriate actions on the results including, but not limited to, the guidance below.
    1. COVID-19 diagnostic test results must be provided, in addition to other pertinent clinical information, to the receiving facility, for any transferred resident, upon receipt of lab test.
    2. Upon identification of a case of COVID-19 in a resident who was recently admitted (within 14 days), the receiving facility must provide these results back to the sending facility to allow for the appropriate response and investigation.

COVID-19 TESTING PLAN FOR ALL STAFF AND RESIDENTS

RESIDENT AND STAFF TESTING

Testing Procedures and Frequency:

  1. Post-testing protocols for residents such as cohorting of residents and separation of those with laboratory confirmed COVID-19 infection from others. (Refer to Cohorting above)
  2. Procedures to obtain staff authorizations for release of laboratory test results to the facility as to inform infection control and prevention strategies.
  3. Work exclusion of staff who test positive for COVID-19 infection, refuse to participate in COVID-19 testing, or refuse to authorize release of their testing results to the facility, until such time as such staff undergoes testing and the results of such testing are disclosed to the facility.
  4. Return to work protocols after home isolation for staff who test positive.
  5. Address staffing (including worker absences).

REPORTING

The facility will submit the following information in a prescribed format through the portal designated by the Office of Emergency Management (“OEM”) and be consistent with available CDC and DOH public health guidance:  

  1. Testing dates;
  2. Numbers of staff and residents that have been tested.
  3. Staff authorizations for release of laboratory test results to the facility so as to inform infection control and prevention strategies.
  4. Work exclusion of staff who have tested positive for the COVID-19 infection, refuses to participate in COVID-19 testing, or refuse to authorize release of their testing results to the facility, until such time as such staff undergoes testing and the results of such testing are disclosed to the facility.
  5. Protocols for returning to work after home isolation for staff who tested positive.
  6. Plans to address staffing (including worker absences) and facility demands due to the outbreak.
  7. Aggregate testing results for the staff and resident populations.
  8. Any other information requested by DOH.
  9. Any and all records related to COVID-19 testing protocols and implementation by the facility shall be made available to DOH, upon request.
  10. If a resident refuses to undergo COVID-19 testing, then the facility shall treat the resident as a “Person Under Investigation”, make a notation in the resident’s chart, notify any authorized family members or legal representatives of this decision, and continue to check temperature on the resident at least twice per day.  Onset of temperature or other symptoms consistent with COVID-19 require immediate cohorting.  At any time, the resident may rescind their decision not to be tested.

Testing shall occur as follows:

Baseline molecular testing of staff and residents completed by May 26, 2020.

  1. Re-testing of individuals who test negative at baseline on May 28, 2020 after baseline testing.
  2. Further re-testing in accordance with CDC guidance, as amended and supplemented.

If a staff member tests positive for COVID-19 (symptomatic or asymptomatic), the facility may permit them to return to work subject to CDC and DOH recommendations as to timeframes and requirements.

By May 19, 2020, an authorized representative of the facility shall submit to DOH an attestation stating that the facility has developed a Plan.

By May 26, 2020, an authorized representative of the facility shall submit to DOH an attestation stating that the facility has implemented a Plan.

Attestations regarding the Plan shall be submitted by email to: LTC.DiseaseOutbreakPlan@doh.nj.gov.

The facility shall submit the following information in a prescribed format through the portal designated by the Office of Emergency Management (“OME”) in Executive Order No. 111 (Murphy).

  • Testing dates.
  • Numbers of staff and residents that have been tested.
  • Aggregate testing results for the staff and resident populations.
  • Any other information requested by DOH.

Any and all records related to COVID-19 testing protocols and implementation by the facility shall be made available to DOH, upon request.

The facility submission of attestations to DOH and information submitted to OEM regarding COVID-19 testing, will be made publicly available and tracked on the NJ COVID-19 Information Hub website.

RESIDENT/STAFF ELIGIBILITY

A. Residents and staff who has or may have been exposed to SARS-COV-2 within the incubation period for COVID-19 (pursuant to current guidelines), and who meets one of the following conditions:

  • Resident/Staff who had close contact (within 6 feet for at least 10 minutes) with someone who tests positive for COVID-19 (with or without symptoms).
  • Healthcare Facilities Workers (with or without symptoms).
  • Resident/Staff with symptoms of COVID-19 infections, including fever, cough, shortness of breath, chills, muscle pain, recent loss of taste or smell, vomiting or diarrhea and/or sore throat.
  • Populations identified by the Department of Health for surveillance purposes at the discretion of the Department.
  • Resident/Staff without symptoms of COVID-19 infection who are prioritized by health departments or clinicians, for any reason. 

INFORMATION ON COLLECTING THE SPECIMEN:

  1. Prior to collecting the specimen from the Resident/Staff, the tester shall provide information to the patient receiving the testing, which shall include but is not limited to the following:
  • Information on how and when to obtain test results.
  • Information for contacting the local health official with the jurisdiction where the resident/staff resides.
  • Information on next steps for the resident/staff to take, including:
    • Information on obtaining follow-up medical care or to address questions about a diagnosis if the resident/staff tests positive for COVID-19.
    • Information about actions to be taken in accordance with guidance as issued and/or amended by the Centers for Disease Control and Prevention (“CDC”) and/or New Jersey Department of Health.

SPECIMEN COLLECTION, TESTING AND TEST RESULTS

  1. Testers may collect a specimen for a SARS-COV-2 molecular test approved by the U.S. Food and Drug Administration (“FDA”), authorized by the FDA through an Emergency Use Authorization or approved by the New Jersey Clinical Laboratory Improvement Services as permitted by the FDA.
  2. Preparation to collect a specimen:
    1. Ensure correct testing materials according to manufacturer instructions and/or the laboratory who will be performing the test.
    2. Ensure appropriate PPE for tester to administer the test such as gloves, gowns, N95 or higher respirator (or surgical mask should a respirator not be available) and eye protection (goggles or face shield).
  3. Instruction to collect a specimen:
    1. By licensed healthcare provider, or trained, supervised personnel.
    2. Follow manufacturer-specific and/or laboratory-specific instructions for specimen collection.
    3. Follow CDC guidelines for Collecting, Handling, and Testing Clinical Specimens for Resident/Staff for Coronavirus Disease 2019, as amended and supplemented.
  4. The laboratory conducting a SARS-COD-2 molecular test on a specimen collected shall report the test results to the facility.
  5. Follow-up:
    1. Test results must be reported to the resident/staff by a representative of the testing location as soon as possible but no later than 2 days after the testing location’s receipt of the test results.  A positive result requires self-isolation per New Jersey Department of Health or local health department recommendations.
    2. Positive and negative results must be reported by the laboratory processing the test results via the New Jersey Department of Health’s Communicable Disease Reporting and Surveillance System or other methods prescribed by the New Jersey Department of Health.

(New Jersey Department of Health Standing Order for COVID-19 Testing – Control Number: 2020-01)

NOTIFICATION OF RESTRICTED AND LIMITED VISITS:

COMMUNICATION

The facility shall communicate through multiple means to inform individuals, including non-essential healthcare personnel, of the visitation restrictions, such as through signage at entrances/exits, letters, emails, phone calls, and recorded messages for receiving calls. 

VISITATION

Recognizing the significant burden of a no visitation policy, The Actors Fund Home has sought ways to permit visitors under certain well-defined circumstances. In compliance with the State of New Jersey Department of Health and CDC, The Actors Fund Home has established a policy with controlled parameters that will help continue to protect our residents from potential exposure to coronavirus while remaining in compliance.

PURPOSE

Balancing COVID-19 safety and visitation restrictions with the well-being of residents in the facility is an urgent priority for The Actors Fund Home

We recognize that isolation has a serious impact on the health and wellbeing of our residents.  Until now, the focus on keeping residents connected with visitors/family members has centered on technology (i.e., Zoom, Facetime, etc.), however this does not fully substitute for in-person visits.  The Actors Fund Home believes the risk of COVID-19 transmission in our facility and the need for visitors/family members interactions can be balanced under the following guidelines:

PROCESS

The facility shall screen and log all visitors entering the facility and all staff at the beginning of each shift.

The facility will actively screen all staff/visitors entering the building (except EMS personnel) for signs/symptoms of COVID-19 or exposure to persons with confirmed COVID-19. Screening will include:

  1. Temperature checks including subjective and/or objective fever equal to or greater than 100.4 F.
  2. Visitors and staff will complete a questionnaire about symptoms and potential exposure which shall include at a minimum:
    1. Whether in the last 14 days, the visitor has had an identified exposure to someone with a confirmed diagnosis of COVID-19, someone under investigation for COVID-19, or someone suffering from a respiratory illness.
    2. If the visitor has been diagnosed with COVID-19 and has not yet met criteria for the discontinuation of isolation per guidance issued by NJDOH and CDC.
    3. Whether in the last 14 days, the visitor has returned from a state on the designated list of states under the 14-day quarantine travel advisory.

The facility will observe anyone entering the building for any signs or symptoms of COVID-19, including but not limited to:

  1. Chills;
  2. Cough;
  3. Shortness of breath or difficulty breathing,
  4. Sore throat;
  5. Fatigue;
  6. Muscle or body aches;
  7. Headache;
  8. New loss of taste or smell;
  9. Congestion or runny nose;
  10. Nausea or vomiting; or
  11. Diarrhea.

Upon screening, the facility will prohibit entry in the building for those who meet one or more of the following criteria:

  • If a visitor exhibits signs or symptoms of an infectious communicable disease, including COVID-19, fever greater than 100.4, chills, cough, shortness of breath or difficulty breathing, sore throat, fatigue, muscle or body aches, headache, new loss of taste or smell, congestion or running nose, nausea or vomiting, or diarrhea.
  • In the past 14 days, has had contact with someone with a confirmed diagnosis of COVID-19, or someone under investigation for COVID-19, or someone ill with respiratory illness.
  • In the past 14 days, if the visitor has returned from a designated state under the 14-day quarantine travel advisory.
  • If a visitor has been diagnosed with COVID-19 and not yet met criteria for the discontinuation of isolation per guidance issued by the NHJDOH.

The facility will establish a designated area for visitors to be screened that accommodates social distancing and infection control standards.  Visitors will be provided with the visitation guidelines upon screening.  The facility will provide graphics to assist residents and visitors in maintaining social distancing and infection control standards.

 

No more than two (2) visitors are permitted at one time per resident.  The facility will use appointments in order to limit the number of visitors inside the building at one time.

When a visitor undergoes screening and is permitted to enter the building, the facility will:

  • Require the visitor to wear a surgical mask.  The facility may require the visitor to use additional forms of PPE as determined by the facility.
  • Provide instruction on hand hygiene, provide instruction on limiting surfaces touched, provide instruction on the use of PPE, and inform visitors of the location of hand hygiene stations, before the visitor enters the building and resident’s room.
  • Advise the person to limit physical contact with anyone other than the resident while in the facility.  For example, practice social distancing with no handshaking, kissing or hugging and remaining six feet apart.
  • Visitation will be provided to the visitor in the resident’s room, if they are in a single room.  If a resident is in a share room, the facility will identify a visitation location that allows for social distancing and for deep cleaning. The facility shall 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 the dining room, etc.).
  • Restrict a visitor from entering the facility if they are unable to demonstrate the proper use of infection prevention and control techniques.

The facility will advise anyone entering the facility to monitor for signs and symptoms of COVID-19 for at least 14 days after exiting the facility. If symptoms occur, the facility will advise the visitor to self-isolate at home, contact their healthcare provider, and immediately notify the facility of the date they were in the facility, the individuals they were in contact with, and the locations within the facility they visited. The facility will immediately screen the individuals of a reported contact, and take all necessary actions based on any findings.

The facility must receive informed consent from the visitor(s) and the resident in writing that they are aware of the possible dangers of exposure to COVID-19 for both the resident and the visitor and that they will follow the rules set by the facility in regard to visitation.  The facility must receive a signed statement from each visitor and resident (if the resident is unable to consent then the consent needs to  be signed by the authorized representative) with a copy provided to the visitor and resident, that they are aware of the risk of exposure to COVID-19 during the visit, that they will strictly comply with the facility policies and procedures during visitation, and that the visitor will notify the facility if they test positive for COVID-19 or exhibit symptoms of COVID-19 within 14 days of the visit.

RETURN TO WORK PRACTICES AND WORK RESTRICTIONS FOR EMPLOYEES WITH CONFIRMED OR SUSPECTED COVID-19

Any employee with confirmed or suspected COVID-19 must be screened by a physician prior to returning to work.

As of April 13, 2020, CDC advises the use of “Test-based strategy as the preferred method for determining when HCP may return to work in healthcare settings”:*

  1. Test-based strategy. Exclude from work until:
    1. 24 hours since the resolution of fever without fever reducing medication and greater than 10 days have passed since the first symptoms appeared. https://www.nj.gov/health/cd/documents/topics/NCOV/Guidance_for_COVID 19_Diagnosed andor_Exposed_HCP.pdf
    2. Improvement in respiratory symptoms (e.g., cough, shortness of breath), and,
    3. Negative results of an FDA Emergency Use Authorized COVID-19 molecular assay for detection of SARS-CoV-2 RNA from at least two consecutive respiratory specimens collected 24 hours apart (total of two negative specimens). See Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for 2019 Novel Coronavirus (2019-nCoV).

If testing is not available, “the Non-test-based strategy” may be used for determining when HCP may return to work:

  1. Non-test –based strategy.  Exclude form work until:
    1. At least 3 days (72 hours) have passed since recovery defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath); and,
    2. At least 7 days have passed since symptoms first appeared.

Health Care Professionals (HCPs) with laboratory-confirmed COVID-19 who have not had any symptoms should be excluded from work until 10 days have passed since the date of their first positive COVID-19 diagnostic test assuming they have not subsequently developed symptoms since their positive test. 

If HCPs had COVID-19 ruled out and have an alternate diagnosis, (e.g., tested positive for influenza), “criteria for return to work should be based on that diagnosis”.

If the test-based strategy will be used, two consecutive nasal swab specimens should be collected for testing at least 24 hours apart.  There is no need to wait for results from the first test to collect the second test.  For example:  April 14 10 AM Test 1 collected; April 15 12PM test 2 collected.  The employee may return to work on the day that both tests have returned negative.

*https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-work.html

NOTIFYING RESIDENTS, STAFF AND FAMILIES WITH A CONFIRMED CASE OR A “PERSON UNDER INVESTIGATION FOR COVID-19.

The facility shall notify all residents and staff members in person and in writing within 24 hours. The facility shall notify families or whoever is designated responsible for the resident via telephone, email or another form of communication within 24 hours, and must follow it up in writing within three days.   This shall happen when a resident or staff member is a confirmed case or a “person under investigation” for coronavirus.

AFTER RETURNING TO WORK, EMPLOYEES SHALL:

  1. Wear a facemask and eye protection at all times in all areas of the facility.
  2. Be restricted from contact with severely immunocompromised residents (e.g. transplant, hematology-oncology) until 14 days after illness onset.
  3. Adhere to hand hygiene, respiratory hygiene, and cough etiquette in CDC’s interim infection control guidelines (e.g., cover nose and mouth when coughing or sneezing, dispose of tissues in waste receptacles.)
  4. Self-monitor for symptoms, and seek re-evaluation from their physician if respiratory symptoms recur or worsen.
  5. Employees should be evaluated by a physician to determine appropriateness of earlier return to work than recommended above.

Employees with symptoms that may mimic coronavirus but are attributed to other diagnosis must obtain medical clearance in the form of a letter signed by a physician attesting that symptoms they may be experiencing (e.g., chronic cough) are due to other causes, and not due to an acute respiratory infection.