The Steven and Alexandra Cohen Pediatric Long Term Care Pavilion Pandemic Emergency Plan

This Pandemic Emergency Plan is prepared in accordance with the New York State Department of Health requirement as detailed in the Dear Administrator Letter (DAL) 20-09 dated August 20, 2020. The Pandemic Emergence Plan is designed to easily identify the information needed to effectively plan for, respond to, and recover from, natural and man-made disasters. The Pandemic Emergency Plan will be reviewed annually and modified as needed.

Plan Availability:

An electronic version of this Pandemic Emergency Plan will be posted on the organization’s website and a printed copy will be available at the security desk.

Effective Date: September 2020


The purpose of the Pandemic Emergency Plan (PEP) is to describe the approach to mitigating the effects of, preparing for, responding to, and recovery from an Infectious Disease/Pandemic Emergency that may disrupt normal operations and require pre-planned response. The incident of a pandemic infectious disease which in humans has increased or threatens to increase in the near future and has the potential to pose a significant public health threat and danger of infection to residents, families and staff of the Steven and Alexandra Cohen Pediatric Long Term Care Pavilion (SNF).

Scope and Design:

This plan is intended to be flexible in every respect. Since it is not possible to predict exactly what the nature or scope of an emergency will be, the plan is intended as a guide to be modified as needed at the direction of authorized and competent authorities. The plan does not prescribe every step of every person in every possible situation. Rather it creates a framework adaptable to various situations. The Pandemic Emergency Plan is incorporated into the organization’s Emergency Management Operations Plan and defines processes in which the SNF provides effective guidance on how to response to pandemic infectious diseases.

The plan is developed with the involvement of Hospital/SNF leadership, including the medical staff. The organization and operation of the plan includes numerous activities/functions under the general direction of the Chief Medical Officer, Director of Infection Prevention, Administrator, Medical Director and Director of Nursing.

During a pandemic emergency that affects the community, the region, or larger area, the Hospital/SNF leaders recognize that the facility’s capacity to accept a surge of patients/residents from other hospitals/SNF may be over-extended.  The potential for an influx of infected patients/residents is addressed in the Infection Control Plan.

By way of clarifying the scope as it relates to the school (Mt. Pleasant-Blythedale Union Free School District), this plan applies to the Hospital/SNF and its employees.  The school follows the requirements of the New York State Education Department relevant to emergency planning. However, the Hospital/SNF and the school are familiar with each other’s emergency plans and the facilities work in concert with each other when there is a need.


The PEP contains general policy elements that are intentionally broad. It is customizable depending on the demographic, location, and current infectious disease threats. It is not comprehensive and does not constitute medical or legal advice.

Every infectious disease is different. The local, state, and federal health authorities will be the source of the latest information and most up-to-date guidance on prevention, case definition, surveillance, treatment, and response related to a specific disease threat.


The goals of the plan:

  • Protect the residents, families and staff from harm resulting from exposure to an emergent infectious disease,

  • Minimize the spread of the pandemic organism,

  • Maintain essential medical and nursing functions,

  • Maintain services for all residents,

  • Minimize social disruptions for residents and their families,

  • Maintain designated par level of supplies and personal protective equipment (PPE),

  • Ensure timely communicable disease reporting,

  • Ensure bed retention of hospitalized residents,

  • Coordinate efforts with community partners.


This PEP is developed from routine and special risk assessment activities of the Hospital/SNF, performance during prior pandemic experience, and implementation of new or revised policies, regulations and/or standards. 

The PEP includes policies and procedures of the responses that are to be followed when a pandemic emergency occurs. Procedures address the emergencies that may include but are not limited to: maintaining services, conserving resources, curtailing services, supplementing resources from outside the local community and stopping admissions. In addition, the PEP describes areas under review to ensure restoration of systems that are critical to providing care, treatment, and services after a pandemic.

Processes related to the implementation of the PEP are documented in specific policies and procedures listed in Attachment A.


The Hospital/SNF leadership recognizes the importance of developing and maintaining a PEP as a way to guide the organization in emergency response and recovery issues.  The leadership of Hospital/SNF includes the CEO/President, COO/CMO/Medical Director, VP for Operations, Chief Nursing Officer, LTC Administrator, LTC Director of Nursing, Director of HR and Director of Infection Prevention as well as other key administrative and clinical leaders who actively participated in developing the PEP.

Infection Control Plan:

  1. The SNF maintains an Infection Preventionist and an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections through the use of current and acceptable standards of practice.

  2. The SNF promotes hand hygiene by providing and encouraging the use of hand sanitizers throughout the unit as well as handwashing.

  3. Appropriate PPE is readily available for staff to mitigate the risk of transmission.

  4. The Director of Infection Prevention (IP) shall research the disease’s specific signs, symptoms, incubation period, route of infection, the risk of exposure, and the recommendations provided by the CDC, OSHA and other relevant local, state and federal public health agencies.

  5. Working with the Medical Director and/or clinical consultants, local and state public health authorities, and others as appropriate, the IP will review and revise internal policies and procedures, environmental cleaning agents and personal protective equipment (PPE) as indicated by the specific disease threat.

  6. The SNF has implemented the following Infection Control/Prevention policies and procedures:

Managing Staff Education on Infectious Diseases:

Staff shall be educated on the exposure risk, symptoms and prevention of the specific disease threat. Special emphasis is placed on reviewing the basic infection prevention strategies such as hand washing and social distancing. New hires will receive education at orientation.

Such education shall include but is not limited to the following:

  • Pandemic related specific infection control and symptoms
  • Risk of exposure/transmission and need for PPE
  • PPE guidance and usage
  • Housekeeping disinfection process
  • Travel restrictions when applicable
  • Testing requirements when applicable
  • Suspension of visitors when applicable
  • Regulatory reporting requirements for pandemic infectious disease
  • Handwashing

Managing Community Partner Communication:

The Hospital/SNF defines its community as Westchester County and the Hudson Valley region. Westchester Medical Center (WMC) is the Regional Resource Center for the Hudson Valley region. The Emergency Planning Team at the Hospital/SNF communicates on a regular basis with its partners at WMC to discuss potential emergencies and direct or indirect effects such emergencies may have on the organization’s operations. 

The Hospital/SNF communicates its needs and vulnerabilities to emergency response agencies and identifies their capabilities in meeting those needs. The emergency response agencies consist of: Valhalla Fire Department, Hawthorne Fire Departments, Mt. Pleasant Police, Westchester County Department of Public Safety, Office of Emergency Management and the Westchester Medical Center RRC. The emergency response agencies meet on a regular basis with members of the Hospital/SNF leadership team. The Hospital/SNF updates these agencies of the vulnerabilities and the needs that are to be met in difference types of emergencies or events. The organization is connected to all of these agencies via a satellite telephone system.

The Hospital/SNF also collaborate with the Public Emergency Preparedness Representatives from New York State Department of Health (NYSDOH), GNYHA, CCLC and HANYS.

Managing Staff Communication:

The SNF maintains a list of all staff members, including emergency contact information, both electronically and at a physical location (HR).

Managing Family Communication:

Upon admission, and at least annually, and prior to any recognized threat, the SNF will educate residents and responsible parties on the Emergency Management Plan and the SNF’s preparedness efforts. In the event of an infectious disease/pandemic event, the SNF will provide information/education regarding the threat to residents, family and staff. During a pandemic, communication methods may include, telephone, flyers/pamphlets, mailings, emails, facility website, facility phone voice recordings and videoconferencing. In addition, for staff this may also include informational postings, and educational in-services.

The SNF maintains a list of all residents authorized family member, and a secondary back-up contact information as available, including telephone number and email address, as available.

Communication will be adapted, as needed, to meet population-specific needs, including cognitively impaired residents, individuals with vision and/or hearing impairments, and individuals with other access and functional needs (i.e., individuals who speak a language other than English).

Limited or restricted visits, which mean less face-to-face communication, can present challenges for both the resident and their loved ones. Recognizing this challenge the following will be initiated:

  1. Residents and families will be provided with educational material about the disease and the SNF’s response strategy at a level appropriate to their interest and need for information.
  2. Visitation information (Expectations During Your Visit) will be posted on the Hospital/SNF website.
  3. The SNF attending physicians shall update family members and/or guardians of infected residents with pandemic infectious disease at least once per day and upon change in condition.
  4. The SNF social worker shall update family members and/or guardians on the number of residents presenting with infection and/or mortality on a weekly basis.
  5. Communication to family members and/or guardians shall be in their preferred mode of communication (mail, email, text or telephone).
  6. The SNF shall offer Virtual Visits, at no cost, for residents and their families and/or friends who request to connect virtually. 

Managing Emergency Staffing

The facility has implemented policy and procedures in order to ensue each resident has sufficient, competent staff to provide daily essential care and needs for the residents served. The policy and procedures establishes contingency strategies to operate the facility within statutory requirements in lieu of staffing shortages that may occur during an emergency.

Managing Supplies and Personal Protective Equipment (PPE)

As per NYSDOH guidance for the COVID-19 during activation of the plan, the Director of Purchasing will monitor the facility’s PPE needs based on “Burn” rates for PPE.

Normal Burn rates will change during a pandemic and facility will base needs on historical data and in coordination with NYSDOH regulations for the specific pandemic.

As part of the emergency resources inventory review, the Hospital/SNF Emergency Management team has identified alternate sources for many of the supplies required during a pandemic. Contact information of primary, secondary, and alternate vendors for all critical supplies, services and equipment is maintained.

Recognizing that there is a risk that some resources may not be available if several organizations are vying for limited supplies, the Hospital/SNF’s Emergency Management Plan contains procedures for stockpiling and managing designated medications and supplies, including PPE. These plans include but are not limited to:

  1. Purchasing necessary supplies for both residents and staff in order to continue to provide services and support to residents. Additionally, replenishing supplies and equipment throughout response and recovery, including PPE, pharmaceuticals and non-medical supplies such as linen, food, water and fuel.
  2. PPE critical supplies are maintained at a two-month (60 day) par level based on facility census and burn rate. The following critical supplies shall be maintained during pre-pandemic phase:
  • N95 Respirators
  • Face Shields
  • Eye Protection
  • Isolation Gowns
  • Gloves
  • Face Masks
  • Sanitizer and Disinfectants in accordance with current EPA guidance.
  1. Through community partnerships there is a potential of sharing of resources and assets with other organizations within the community as well as within the region
  2. Once a pandemic outbreak occurs or once supplies and services are affected by a pandemic outbreak elsewhere, the Directors of Pharmacy and Purchasing shall rely on business partners and critical supply list to identify our supply needs. Once a supply need is identified, the Director of Pharmacy and Purchasing shall ensure the item is ordered and secured. Should supplies become depleted unexpectedly, the CMO and LTC Administrator are to be notified immediately.
  3. In the event resource replenishment cannot be accomplished, the SNF shall develop alternate strategies for resource conservation and/or service reduction. This shall be done in coordination with the appropriate department heads, purchasing, pharmacy, dietary and facilities management. In the event that resources shortfalls are projected, the following actions will be implemented: 
    • Immediate notice to the CEO, CMO, LTC Administrator and Infection Preventionist when expected use of any item on the Emergency Supply List will exceed inventory or when such inventory is insufficient for the needs of the SNF on a running 60 day period.

    • Procurement from alternate or nontraditional vendors

    • Procurement form communities outside the affected region

    • Resource substitution

    • Resource sharing arrangements with mutual aid partners

    • Request for external stockpile support form NYSDOH

  4. The Director of Pharmacy shall review vital medications with the Medical Director to identify vital medications with a plan to stockpile for those medications.

  5. The Medical Director shall review resident medication regimen to identify medications that can be reduced or discontinued in case of medication shortages as a result of a pandemic.

  6. A review of current supply and weekly usage of environmental cleaning agents with the Housekeeping and Dietary Supervisors and calculate and purchase sufficient supply.

  7. The Food Service Director will maintain emergency water supply according to policy and procedure with the guidance of NYSDOH regulations.

  8. The process for communicating with vendors of essential supplies, services, and equipment is described in the organization’s Emergency Operation Procedure. A list of primary and alternative supply vendors have been identified by supply type, supplier, address, telephone number, email address and fax. This information is maintained by the Directors of Pharmacy and Purchasing.

Managing Communicable Disease Reporting:

The SNF complies with reporting of suspected or confirmed communicable disease as mandated under New York State Sanitary Code. Any outbreak or significant increase in nosocomial infections above the norm of baseline in residents or employees are reported to NYSDOH. Reporting is done by Infection Prevention (IP) via the Nosocomial Outbreak Reporting Application (NORA), a NYSDOH Health Commerce System Application, or via fax.

A single case of a reportable communicable disease or any unusual disease (defined as a newly apparent or emerging disease or syndrome that could be caused by a transmissible infectious agent or microbial toxin) must be reported to the local health department where the resident resides. In addition, if the reportable communicable disease is suspected or confirmed to be acquired at the nursing home, it must also be reported to NYSDOH via NORA or by fax.

Communicable diseases are to be reported within 24 hours of identification. However, some diseases may warrant prompt action and must be reported immediately by telephone. If additional information is required, the IP shall contact the NYSDOH regional epidemiologist or NYSDOH Central Office Healthcare Epidemiology and Infection Control Program. The IP shall report any unusual occurrences or clustering of communicable or reportable diseases to the CMO, Medical Director, Administrator and DON.

Managing Cohorting or Isolation of Infected Residents

Cohorting refers to the grouping of residents with the same condition in the same location (e.g., room or area). For purposes of the PEP, the term cohorting refers to maintaining residents who are infected with an infectious pandemic disease or are suspected to have an infectious pandemic disease in the same space that is separate from those residents who do not present with the disease or do not have exposure to the pandemic disease. Staff caring for the cohorted resident(s) shall be assigned to caring only for the cohorted residents.

The isolation areas will have proper signage and identification of the area(s) for residents with the pandemic illness, including demarcating reminders for healthcare personnel and residents using signage with a Stop Sign. The areas selected for cohorting residents will have barriers to prevent other residents from entering the area.

The goal of cohorting is to minimize interaction with infectious residents from non-infected residents as much as possible.

Managing Leave of Absence Request

The SNF wants to ensure the health, safety, and quality of life of residents. We understand residents and families may want to spend more time together, especially during the holiday season, outside of the facility. NYSDOH guidance shall be followed for residents returning from a leave of absence.  

Residents who leave the facility should be reminded to follow all recommended IPC practices including source control, physical distancing, and hand hygiene. Individuals accompanying residents (i.e., family members) should be educated about IPC practices and should assist the resident with adherence.  

Residents and their families are encouraged to find creative and innovative ways to spend time together especially during the holidays. Data has shown that small family gatherings contribute to the spread of a pandemic organism and that visits with family members outside of the facility could increase the risk of exposure to a pandemic organization.

Managing New Admissions/Readmissions And Residents Who Leave The Facility

Residents with a confirmed case of a SARS-CoV-2 infection who have not met criteria for discontinuation of Transmission-Based Precautions should be placed in a designated area separate from the resident population. Refer to CDC and NYSDOH for guidance.

NYSDOH guidance shall be followed for all new admissions, readmissions and those who have been out of the facility for greater than 24 hours.

  • Exceptions include residents within 3 months of a SARS-CoV-2 infection and fully vaccinated residents as indicated by the CDC.
  • Facilities located in areas with minimal to no community transmission might elect to use a risk-based approach for determining which residents require quarantine upon admission. Decisions should be based on whether the resident had close contact with someone with SARS-CoV-2 infection while outside the facility and if there was consistent adherence to IPC practices in healthcare settings, during transportation, or in the community prior to admission.

In most circumstances, quarantine in not recommended for residents who leave the facility for less than 24 hours (i.e., for medical appointments, community outings with family or friends) and do not have close contact with someone who is infected.

Residents going to medical appointments, regular communication between the medical facility and the facility is essential to help identify residents with potential exposure or symptoms of disease before they reenter the facility so that proper precautions can be implemented.

Managing Restriction of Visitation

Under normal circumstances, the SNF welcomes residents’ visitors 24/7. We understand in-person visits provide support and reassurance for residents and families alike, we pride ourselves on being a resident, and family centered facility.

During a pandemic, we must do everything we can to prevent the spread of the infectious disease and protect our residents, staff and visitors. When fewer people enter the facility, there is a greater likelihood that more residents and caregivers will stay safe and well. There is also a need to conserve PPE for staff so they can adequately and safely care for residents.

In order to do this, the facility may have to put limits on the number of visitors entering the facility or stop visitation all together. When mandated by NYSDOH visitors will be restricted, except for certain situations, which must be approved by administration.

A summary of our policy:

  • The facility shall follow NYSDOH guidance for all visitors with testing and screening. Additionally:
    • The caregiver must be in good health and remain in good health during the resident’s stay.
    • All visits outside the policy guidelines must be approved by administration.
    • If a visitor is approved based on the criteria above, the visitor will need to follow safety precautions. The visitor will be screened for symptoms, such as cough, fever, chills or shortness of breath and will not be able to visit if symptomatic.
    • The proper PPE will be required to enter the facility.
    • Visitation restrictions mandated by NYSDOH shall take precedence over facility policy.

Managing Bed Reservation:

  1. The SNF shall honor a resident’s right to return to the facility following a hospitalization unless the facility can no longer meet the resident’s needs. In such case, the resident representative shall be advised of this decision.
  2. The resident shall be medically stable with respect to the pandemic related infectious disease.
    • Prior to admission, the Admission Department shall advise the resident representative of the need for isolation and/or precautions, probable duration for isolation precautions and the plan of care.

    • Should the resident to be re-admitted still be infectious, they will be admitted to a private room pending availability or cohort with another resident presenting with the same infectious disease.

    • When the facility can no longer meet the needs of a resident, the SNF will cooperate with the alternative receiving facility.

    • The SNF will give priority consideration to re-admit the resident should their condition improve enabling the facility to meet their needs.

Residents 21 years and older - who have resided in the SNF for 30 days or more and whose hospitalization exceeds the bedhold period will be readmitted to the facility immediately upon the first available bed in a semi-private room if the resident requires the services provided by the facility and is eligible for Medicaid nursing home services.

Residents under 21 years of age – If eligible for Medicaid nursing home services the resident shall be transferred to their original bed upon discharge from the hospital.

Managing Contaminated Waste:

The facility’s hazardous waste program involves storage, disposal and minimization of hazardous waste. The requirements of the program apply to chemical waste, regulated medical waste (RMW) and certain categories of non-hazardous chemical waste. RMW is a waste product that contains free flowing blood/body fluid. Also included in this category are SHARPS such as needles with attached syringes, all blades, used or broken blood tubes, vials, scissors etc. Hazardous waste of any type is disposed of in Department of Transportation approved designated RMW locked containers and never discarded in the trash in any amount. Nursing and Environmental Services staff monitor and ensure containers are changed prior to exceeding the designated capacity.

Returning to Normal Operations/Recovery:

Recovery services focus on the needs of residents and staff to help restore the facility’s pre-disaster physical, mental, social, and economic conditions. The facility will maintain review of, and implement procedures provided in NYSDOH and CDC recovery guidance that is issued at the time of each specific infectious disease or pandemic event, regarding how, when, which activities/procedures/restrictions may be eliminated, restored and the timing of when those changes may be executed.

The following will be reviewed:

  • The SNF shall implement guidance provided by NYSDOH and the CDC regarding the specific infectious disease.

  • The SNF shall review the impact of the physical, economic and social challenges encountered during the pandemic and adjust recovery actions to restore services to full, normal operations.

  • Continuously monitor recovery and prepare actions.

  • Provide updates to residents, families and staff concerning recovery and next pandemic wave efforts.

  • Ensure communication and information-sharing channels remain open with residents, families and staff.

  • Quickly address any rumors and misinformation.

  • Assess shortage impacts on the facility. Assess cost to prepare for the next wave of illness.

  • Monitor international and national health information sources for any updates on the next pandemic waves.

  • Address fear and grief caused by the infectious pandemic outbreak.

  • Mitigate delays in supply chain recovery.

The Pandemic Emergency Plan has been approved by:

Scott Klein, MD
Executive VP, CMO and COO/ Medical Director

Elena Nogueira-Lopez, LNHA

Revised 6/2022

Index of Policies and Procedures

  1. Bedside Virtual Visits
  2. Cleaning and Disinfection of Patient Care Units and Patient Care Equipment
  3. Control of Respiratory Viral Infection
  4. Expectations During Your Visit/Visiting Hours
  5. Epidemic/Pandemic Plan: Management of Influx of Infectious Patients
  6. Family Communication
  7. Infection Prevention – COVID19
  8. Management of Hazardous and Regulated Medical Waste
  9. Pharmacy Procurement of Medications
  10. Reportable Diseases and Conditions
  11. Resident Cohort Plan
  12. Staff Education – Infection Prevention
  13. Leave of Absence Plan (LOA) During a Pandemic
  14. Emergency Planning: Staffing