pandemic policies and procedures title number

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____________________________________________________________________________________________ This policy and procedure is not intended to replace the informed judgment of individual physicians, nurses or other clinicians nor is it intended as a statement of prevailing community standards or minimum standards of practice. It is a suggested method and technique for achieving optimal health care, not a minimum standard

below which residents necessarily would be placed at risk.

PANDEMIC

Policies and Procedures

Title Number Staffing HCRMS/Pandemic/.0001.06 Person-Person Transmission HCRMS/Pandemic/.0002.06 Gloves and Handwashing HCRMS/Pandemic/.0003.06 Hand Hygiene Technique HCRMS/Pandemic/.0004.06 Antiviral Agent Administration HCRMS/Pandemic/.0005.06 Influenza Vaccine HCRMS/Pandemic/.0006.06 Dietary Sanitation HCRMS/Pandemic/.0007.06 Environmental Rounds HCRMS/Pandemic/.0008.06 Environmental Rounds Tool HCRMS/Pandemic/.0009.06 Employee Illness HCRMS/Pandemic/.0010.06 Employee Illness Tracking Log HCRMS/Pandemic/.0011.06 Visitor Restrictions HCMRS/Pandemic/.0012.06




PANDEMIC – STAFFING CHALLENGES

Policy and Procedure

Policy: It is the policy of this facility to provide a safe environment for our residents by ensuring that staffing ratios meet or exceed state requirements as dictated by resident acuity level. Procedure:

1. The general orientation process will include educating new employees on the facility policy for absenteeism including reporting employee illness.

2. Documentation of the general orientation process will be maintained in the

individual employee personnel record.

3. Training on reporting employee illness and absenteeism is identified on the in-service calendar of mandatory training and will be offered at least annually or in the event illness interferes with the facility’s ability to staff the facility.

4. Documentation of individual employee attendance at mandatory training

sessions will be maintained in the individual employee record. Failure to complete a mandatory training session may result in the employee being removed from the staffing schedule until successful completion of mandatory training is complete.

5. Staffing sheets will be completed by the unit manager or designee prior to each shift and will identify each employee assignment.

6. In the event of employee call-ins, the staffing sheets will be adjusted to meet the needs of the residents

7. The shift supervisor or department manager will monitor staffing levels and ratios to ensure that adequate staffing is available for each shift.

8. The Administrator will authorize the use of transportation services or

agency/contingent staffing as necessary to ensure adequate staff is in the center to provide care.

9. Lodging and meals will be offered to employees and volunteers as needed to

ensure that adequate staff is in the center to provide care.

10. Department managers and supervisors are required to remain in the center for the duration of the emergency event to ensure continuity of care and safety for residents, employees, and visitors.




11. The Dietary Department will be responsible to maintain an adequate food supply

to satisfy the needs of the facility during emergency events.

12. Additional precautions, instruction and intervention will be instituted by the Administrator, Director of Nursing or their designee as necessary.

13. Residents will be co-horted as necessary to ensure care needs are met during

emergency events.

14. Families/responsible parties of residents requiring minimal care and supervision will be contacted and afforded the opportunity to move resident to alternative settings (i.e., home) during the emergency event.

15. Family members who express an interest to stay with their loved one to assist in

the provision of care will be provided with daily essentials such as meals, toiletries, etc.

I have read, understand and agree to adhere to the requirements outlined in this policy and procedure. Administrator Signature: Date: Medical Director Signature: Date: Review Dates Related Policies: Person-to-Person Transmission HCRMS/Pandemic/.0002.06 Influenza Vaccine HCRMS/Pandemic/.0006.06 Employee Illness HCRMS/Pandemic/.0010.06 Employee Illness Tracking Log HCRMS/Pandemic/.0011.06




PANDEMIC – PREVENTION OF PERSON-TO-PERSON TRANSMISSION

Policy and Procedure Policy: It is the policy of this facility to institute appropriate infection control practices to assist in preventing the spread of infection.

Procedure: 1. The general orientation process will include training on appropriate infection

control practices that adhere to the Centers for Disease Control guidelines. 2. Documentation of the general orientation process and training will be

maintained in the individual personnel record.

3. Annual training on Infection Control principles and practices will be provided as a mandatory training.

4. Documentation of attendance at mandatory training will be maintained in the

individual employee record.

5. Employees who fail to meet the mandatory training requirements will be removed from the active schedule until successfully completing the mandatory training.

6. The following Droplet Precautions will be implemented immediately when a

resident is suspected or diagnosed with influenza: a. Place a resident who is diagnosed to have influenza in a private room and

promptly perform rapid diagnostic laboratory tests to facilitate early downgrading of infection-control precautions to the minimum required for the resident’s infection.

i. If a private room is not available, place the resident in a room with a resident(s) who has active infection with the same microorganism but with no other infection (cohorting).

ii. If a private room is not available and cohorting is not achievable, consider the epidemiology of the microorganism and the resident population when determining resident placement.

iii. Consultation with infection control professionals is advised before resident placement.

b. Wear a surgical mask upon entering the resident’s room or when working within 3 feet of the resident.

c. Limit the movement and transport of the resident from the room to those for essential purposes only. If resident movement or transport is necessary, have the resident wear a surgical mask, if possible, to minimize droplet dispersal by the resident.




d. 7. The following Contact Precautions will be implemented immediately when a

resident is suspected or diagnosed with influenza: a. In addition to wearing gloves as outlined under Standard Precautions, wear

gloves (clean, nonsterile gloves are adequate) when entering the room. b. During the course of providing care for a resident, change gloves after

having contact with infective material that may contain high concentrations of microorganisms (fecal material and wound drainage).

c. Remove gloves before leaving the resident’s room and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent.

d. After glove removal and handwashing, ensure that hands do not touch potentially contaminated environmental surfaces or items in the resident’s room to avoid transfer of microorganisms to other residents or environments.

e. In addition to wearing a gown as outlined under Standard Precautions, wear a gown (a clean, nonsterile gown is adequate) when entering the room if you anticipate that your clothing will have substantial contact with the resident, environmental surfaces, or items in the resident’s room, or;

f. If the resident is incontinent or has diarrhea, an ileostomy, a colostomy, or wound drainage not contained by a dressing, contact precautions should be used.

g. Remove the gown before leaving the resident’s environment. h. After gown removal, ensure that clothing does not contact potentially

contaminated environmental surfaces to avoid transfer of microorganisms to other residents or environments.

i. 8. Resident Care Equipment

a. When possible, dedicate the use of non-critical resident care equipment to a single resident (or cohort of residents infected or colonized with the pathogen requiring precautions).

b. If use of common equipment or items is unavoidable, then adequately clean and disinfect them before use for another resident.

c. 9. Compliance with this policy will be monitored by clinical nurse managers or

designee. Issues of non-compliance will be addressed immediately and a report summarizing findings and corrective actions will be forwarded to the Quality Assurance Committee for review.




I have read, understand and agree to adhere to the requirements outlined in this policy and procedure. Administrator Signature: Date: ______ Medical Director Signature: ______ Date: ______ Review Dates: _________ ___ __ __ Related Policies: Staffing HCRMS/Pandemic/.0001.06 Gloves and Handwashing HCRMS/Pandemic/.0003.06 Hand Hygiene Technique HCRMS/Pandemic/.0004.06




PANDEMIC - GLOVES AND HANDWASHING


Policy: It is the policy of this facility to institute appropriate infection control practices to assist in preventing the spread of infection. Procedure:

1. The general orientation process will include training on appropriate infection control practices that adhere to the Centers for Disease Control guidelines.

2. Documentation of the general orientation process and training will be





5. Employees who fail to meet the mandatory training requirements will be removed from the active schedule until successfully completing the mandatory training

6. In addition to wearing gloves as outlined under Standard Precautions, direct care

staff are required to wear gloves (clean, nonsterile gloves) when entering the room of a resident being maintained in a respiratory isolation environment.

7. During the course of providing care for the resident, change gloves after having

contact with infective material that may contain high concentrations of microorganisms (used tissues, pillow cases, sheets, etc.).

8. Remove gloves before leaving the resident's room and wash hands immediately

with an antimicrobial agent or a waterless antiseptic agent.

9. After glove removal and handwashing, ensure that hands do not touch potentially contaminated environmental surfaces or items in the resident's room to avoid transfer of microorganisms to other residents or environments.

10. Hands should be washed each time direct contact is made with any resident

and/or resident belongings. Hands should also be washed immediately after using restrooms, sneezing, blowing nose, providing direct care and when gloves are removed.




11. Nurse managers or designee will monitor compliance for appropriate use of

gloves and handwashing on a daily basis. Areas identified as non-compliant will be addressed immediately and a summary of findings and outcomes will be presented to the Quality Assurance Committee for review.

I have read, understand and agree to adhere to the requirements outlined in this policy and procedure. Administrator Signature: Date: Medical Director Signature: Date: Review Dates: Related Policies: Person-Person Transmission HCRMS/Pandemic/.0002.06 Hand Hygiene Technique HCRMS/Pandemic/.0004.06 Environmental Rounds HCRMS/Pandemic/.0008.06 Environmental Rounds Tool HCRMS/Pandemic/.0009.06




PANDEMIC – HAND HYGIENE TECHNIQUE


Policy: It is the policy of this facility to institute appropriate infection control practices to assist in preventing the spread of infection.


control practices and hand hygiene technique that adhere to the Centers for Disease Control guidelines.







6. Rings, watches, and bracelets shall be removed before beginning handwashing.

7. When decontaminating hands with an alcohol-based hand rub, apply product to

palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. Follow the manufacturer's recommendations regarding the volume of product to use.

8. When washing hands with soap and water, wet hands first with water, apply an

amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds or as recommended by the product manufacturer, covering all surfaces of the hands and fingers.

9. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to

turn off the faucet. Avoid using hot water unless it is recommended by the manufacturer, as repeated exposure to hot water may increase the risk of dermatitis.

10. Liquid, leaflet or powdered forms of plain soap are acceptable when washing

hands with a non-antimicrobial soap and water.




11. Multiple-use cloth towels of the hanging or roll type are not recommended by

the Centers for Disease control and will not be used in this facility. 12. Direct care staff will be monitored for compliance with recommended hand-

hygiene practices and will be provided with information regarding their performance.

I have read, understand and agree to adhere to the requirements outlined in this policy and procedure. Administrator Signature: Date: Medical Director Signature: ________ Date: Review Dates: ___ ________

Related Policies: Person-Person Transmission HCRMS/Pandemic/.0002.06 Gloves and Handwashing HCRMS/Pandemic/.0003.06 Environmental Rounds HCRMS/Pandemic/.0008.06 Environmental Rounds Tool HCRMS/Pandemic/.0009.06




PANDEMIC – ANTIVIRAL AGENT ADMINISTRATIONS Policy and Procedure

Policy: It is the policy of this facility that if an outbreak of influenza is suspected or recognized, anti-viral medications may be initiated. Following the guidelines recommended by the Centers for Disease Control, under the direct supervision of the Medical Director and pursuant to a physician’s order, antiviral medications may be administered to residents unless contraindicated by health conditions or if treatment is refused by the resident or responsible party. Procedure: 1. Amantadine, rimantadine, or oseltamivir, if available, may be administered as

prophylaxis to residents without influenza illness on the involved unit for whom the antiviral agent is not contraindicated (regardless of whether they received influenza vaccinations during the previous fall). A physician’s order will be obtained for each resident prior to administration of any medication.

2. The antiviral agent may be administered for a minimum of 2 weeks or until

approximately 1 week after the end of the outbreak. 3. Administration of the antiviral agent(s) for prophylaxis may not be delayed unless the

results of diagnostic tests to identify the infecting strain(s) can be obtained within 12-24 hours after specimen collection.

4. Amantadine, rimantadine, oseltamivir, or zanamivir may be administered to

residents acutely ill with influenza, within 48 hours of illness onset. The Medical Director will determine which antiviral agent is appropriate for the type of influenza virus circulating in the community.

5. Antiviral agent(s) (amantadine, rimantadine, or oseltamivir) may be offered for

prophylaxis to unvaccinated personnel for whom the antiviral agent is not contraindicated and who work on the involved unit or are taking care of residents at high-risk. A physician order must be obtained from the employee’s attending physician prior to administration.

6. Antiviral prophylaxis may be considered for all healthcare personnel, regardless of

their vaccination status, if the outbreak is caused by a variant of influenza that is not well matched by the vaccine. A physician order must be obtained from the employee’s attending physician prior to administration.

7. Antiviral administration may be discontinued if laboratory tests confirm or strongly

suggest that influenza is not the cause of the facility outbreak.




8. If the cause of the outbreak is confirmed or believed to be influenza and vaccine has been administered only recently to susceptible residents and personnel, a physician orders will be obtained to continue prophylaxis with an antiviral agent until 2 weeks after the vaccination was received.

9. To reduce the potential for transmission of drug-resistant virus, contact between

persons at high risk for complications from influenza and residents or personnel who are taking an antiviral agent for treatment of confirmed or suspected influenza may be prohibited during treatment and for 2 days after the discontinuation of treatment.

I have read, understand and agree to adhere to the requirements outlined in this policy and procedure. Administrator Signature: Date: Medical Director Signature: ________ Date: Review Dates: ___ ________ Related Policies: Influenza Vaccine HCRMS/Pandemic/.0006.06 Employee Illness HCRMS/Pandemic/.0010.06 Employee Illness Tracking Log HCRMS/Pandemic/.0011.06




PANDEMIC – INFLUENZA VACCINE




control practices and benefits/risks of influenza vaccination that adhere to the Centers for Disease Control guidelines.







6. Beginning in October each year, inactivated influenza vaccine will be offered to

all personnel including night and weekend staff.

7. Throughout the influenza season, the vaccine will be available to newly hired personnel and to those who initially refuse vaccination.

8. If vaccine supply is limited, highest priority will be given to employees caring for

residents at greatest risk for severe complications from influenza infection.

9. Education regarding the benefits of vaccination and the potential health consequences of influenza illness for themselves and their patients will be provided annually.

10. Inactivated influenza vaccine will be made available at the work site, free of

charge, as part of employee health program.




11. A consent form will be reviewed and signed by the employee prior to receiving the vaccine or if the vaccine is refused. The signed form will be maintained in the employee personnel file.

12. Employees will be screened for any signs and symptoms of illness prior to administering the influenza vaccine.

13. Influenza vaccine will not be administered to any employee exhibiting signs or

symptoms of illness. 14. Employees receiving the influenza vaccine will be monitored for 48 hours for

signs or symptoms of new onset infection (runny nose, cough, sore throat, etc.)

15. Employees exhibiting signs or symptoms of newly acquired infection will be immediately removed from resident care areas and referred to their primary care physician for immediate evaluation and treatment.

16. Employees exhibiting signs or symptoms of newly acquired infection will be

removed from the facility work schedule until such time as symptoms have subsided or the employee receives a release to work signed by their primary care physician.

I have read, understand and agree to adhere to the requirements outlined in this policy and procedure. Administrator Signature: Date: Medical Director Signature: ________ Date: Review Dates: ___ ________ Related Policies: Staffing HCRMS/Pandemic/.0001.06 Person-Person Transmission HCRMS/Pandemic/.0002.06 Employee Illness HCRMS/Pandemic/.0010.06 Employee Illness Tracking Log HCRMS/Pandemic/.0011.06




PANDEMIC – DIETARY SANITATION


Policy: It is the policy of this facility to institute appropriate infection control practices to assist in preventing the spread of infection. Procedure:

1. The general orientation process for dietary personnel will include training on appropriate infection control practices that adhere to the Centers for Disease Control guidelines.







6. All food handling will be performed using disposable gloves, utensils that prevent

direct contact with hands and container covers to prevent the spread of infection.

7. All utensils will be sanitized per manufacturer’s recommendations with special

attention placed on cutting boards, knives, and other utensils used to handle or store raw poultry.

8. Temperatures of wash and rinse cycles of dish machines will be logged at each

meal. Requirements for temperatures needed to reach adequate sanitation per the manufacturer’s recommendations are printed on the machines.

9. The sanitizing agent used in the 3 compartment sink will be verified with a test

strip and logged with each use (as parts per million).

10. Refrigerator and freezer temperature logs will be completed at least daily for all units that store resident food. Freezers should be < 0 degrees F. Refrigerators should be < 41 degrees F.




11. Each menu item shall be temped and recorded before meal service. Hot foods

should be held at > 140 degrees F. Cold foods should be held at < 41 degrees F.

12. Food will be stored appropriately to avoid cross contamination (i.e., raw meats are not thawing above items that will not be cooked before service).

13. Prepared food items will be labeled and dated and discarded on the fourth day.

14. Scheduled, documented sanitation rounds will be performed by the Director of

Food Service or designee to ensure compliance with sanitation expectations. I have read, understand and agree to adhere to the requirements outlined in this policy and procedure. Administrator Signature: Date: Medical Director Signature: ________ Date: Review Dates: ___ ________ Related Policies: Person-Person Transmission HCRMS/Pandemic/.0002.06 Gloves and Handwashing HCRMS/Pandemic/.0003.06 Hand Hygiene Technique HCRMS/Pandemic/.0004.06




PANDEMIC – ENVIRONMENTAL ROUNDS



Procedure: 1. The general orientation process for will include training on appropriate infection

control practices that adhere to the Centers for Disease Control guidelines. 2. Documentation of the general orientation process and training will be




individual employee record. 5. Employees who fail to meet the mandatory training requirements will be

removed from the active schedule until successfully completing the mandatory training.

6. Regular environmental rounds will be performed by the Housekeeping supervisor

or designee and outcomes shall be documented on the “Environmental Rounds Tool”.

7. During outbreaks of influenza, the Housekeeping supervisor or designee shall

perform environmental rounds daily to ensure necessary equipment/supplies are readily available in all resident rooms.

8. Rounds shall be documented daily on the “Environmental Rounds Tool” and

areas identified as not compliant will be addressed immediately. 9. Environmental Rounds will be discussed at the interdisciplinary, stand up

meeting daily until such time as the Medical Director has indicated that the influenza outbreak has subsided.

10. The Quality Assurance Committee shall review the outcomes of Environmental

Rounds and assist in defining criteria and corrective action.




I have read, understand and agree to adhere to the requirements outlined in this policy and procedure. Administrator Signature: Date: Medical Director Signature: ________ Date: Review Dates: ___ ________ Related Policies: Person-Person Transmission HCRMS/Pandemic/.0002.06 Gloves and Handwashing HCRMS/Pandemic/.0003.06 Hand Hygiene Technique HCRMS/Pandemic/.0004.06 Environmental Rounds Tool HCRMS/Pandemic/.0009.06


____________________________________________________________________________________________ This policy and procedure is not intended to replace the informed judgment of individual physicians, nurses or other clinicians nor is it intended as a statement of prevailing community standards or

minimum standards of practice. It is a suggested method and technique for achieving optimal health care, not a minimum standard below which residents necessarily would be placed at risk.

19

ROUNDS CHART Date: Signature:

Any area identified as “No” or “N/A” requires documentation of corrective action.

ROOM # TISSUES AT BEDSIDE

WASTE BASKET

AVAILABLE

HAND SANITIZER AVAILABLE

SOAP/WATER PAPER TOWELS

DISPOSABLE GLOVES

IN ROOM

CALL LIGHT IN REACH

FRESH ICE WATER WITH COVER

Copyright © 2017 HCRMS, LLC. All Rights Reserved.

_____________________________________________________________________________________________ This policy and procedure is not intended to replace the informed judgment of individual physicians, nurses or other

clinicians nor is it intended as a statement of prevailing community standards or minimum standards of practice. It is a suggested method and technique for achieving optimal health care, not a minimum standard below which

residents necessarily would be placed at risk.

EMPLOYEE ILLNESS


Procedure: 1. The general orientation process will include training on expectations of employees

when illness occurs and appropriate infection control practices that adhere to the Centers for Disease Control guidelines.

2. Documentation of the general orientation process and training will be maintained in

the individual personnel record.





6. Employee illness/call-ins will be logged on the “Employee Illness Tracking Log” by

the shift supervisor/facility manager.

7. Documentation on the log shall include the date and time the employee called in, employee name, department, date of onset, type of symptoms, and the supervisor’s initials.

8. The Employee Illness Tracking Log will be maintained in a confidential manner and

only be reviewed by designated managers during periods of disease outbreaks.

9. Patterns of illness shall be reported to the Medical Director immediately to assist in developing a plan of action to protect residents, other employees, and visitors from contagious disease processes.

10. The health department will be notified of any contagious disease outbreak at the

direction of the Medical Director.

11. The Quality Assurance Committee will review and update protocols as necessary to meet the needs of the center throughout the emergency period.


_____________________________________________________________________________________________ This policy and procedure is not intended to replace the informed judgment of individual physicians, nurses or other

clinicians nor is it intended as a statement of prevailing community standards or minimum standards of practice. It is a suggested method and technique for achieving optimal health care, not a minimum standard below which

residents necessarily would be placed at risk.

I have read, understand and agree to adhere to the requirements outlined in this policy and procedure. Administrator Signature: Date: Medical Director Signature: ________ Date: Review Dates: ___ ________ Related Policies: Staffing HCRMS/Pandemic/.0001.06 Person-Person Transmission HCRMS/Pandemic/.0002.06 Gloves and Handwashing HCRMS/Pandemic/.0003.06 Hand Hygiene Technique HCRMS/Pandemic/.0004.06 Antiviral Agent Administration HCRMS/Pandemic/.0005.06 Influenza Vaccine HCRMS/Pandemic/.0006.06 Employee Illness Tracking Log HCRMS/Pandemic/.0011.06


_____________________________________________________________________________________________ This policy and procedure is not intended to replace the informed judgment of individual physicians, nurses or other clinicians nor is it intended as a statement of prevailing community

standards or minimum standards of practice. It is a suggested method and technique for achieving optimal health care, not a minimum standard below which residents necessarily would be placed at risk.

EMPLOYEE ILLNESS TRACKING LOG Date Time Employee Name Department Date of

Onset

Symptoms Supervisor

Initials*

This log is maintained for the purpose of tracking employee illness and per HIPAA regulations is considered a confidential document. Reviewing the

information provided on this log is prohibited unless approved by the facility Administrator and/or the Quality Assurance Committee.

*Supervisor Initials = manager of building at time of call-in

Copyright © 2017 HCRMS, LLC. All Rights Reserved. _____________________________________________________________________________________________

This policy and procedure is not intended to replace the informed judgment of individual physicians, nurses or other clinicians nor is it intended as a statement of prevailing community standards or minimum standards of practice. It is a

suggested method and technique for achieving optimal health care, not a minimum standard below which residents necessarily would be placed at risk.

PANDEMIC – VISITOR RESTRICTIONS


Procedure: 1. The general orientation process will include training on expectations of employees

when illness occurs and appropriate infection control practices that adhere to the Centers for Disease Control guidelines.

2. Documentation of the general orientation process and training will be maintained in

the individual personnel record.





6. In the event an outbreak of influenza has been confirmed by the Medical Director in

conjunction with the Department of Health, visitors to the facility may be limited or prohibited.

7. Visitation during the “Visitor Restricted” period will be limited to emergency personnel,

medical staff, hospice providers, and family members of acutely ill residents requiring transfer to acute care or end of life care.

8. Postings will be located at all entrance and exits indicating the onset date of restriction,

estimated length of restriction, emergency contact information for Administrator and/or designee and Medical Director contact information.

9. All questions regarding visitor restrictions or general facility policy and procedures shall

be addressed by the facility Administrator, Director of Nursing and/or designee during off hours.

10. Visitors refusing to maintain compliance with visitor restrictions orders shall be

counseled by the Medical Director of the potential risks associated with non-compliance.

Copyright © 2017 HCRMS, LLC. All Rights Reserved. _____________________________________________________________________________________________

This policy and procedure is not intended to replace the informed judgment of individual physicians, nurses or other clinicians nor is it intended as a statement of prevailing community standards or minimum standards of practice. It is a

suggested method and technique for achieving optimal health care, not a minimum standard below which residents necessarily would be placed at risk.

11. The Quality Assurance Committee is responsible for monitoring the outcomes of all unusual occurrences including those related to visitor restrictions.

I have read, understand and agree to adhere to the requirements outlined in this policy and procedure. Administrator Signature: Date: Medical Director Signature: ________ Date: Review Dates: ___ ________ Related Policies: Person-Person Transmission HCRMS/Pandemic/.0002.06

pandemic policies and procedures title number

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