Pandemic Emergency Plan (PEP)

Revision: 8/2026

It is a requirement under Chapter 114 of the Laws of 2020, specifically related to Section 2803 of the public health law; subdivision 12 to have a special focus for emergency preparedness on pandemics and that each skilled nursing facility under NYS DOH regulation is to create a detailed Pandemic Emergency Plan (PEP). The following plan submitted on behalf of Chestnut Park Commons Rehabilitation & Nursing Center will feature NYS DOH PEP requirements within Annex E: Infectious Disease/Pandemic Emergency, Hazard Annex K: Infectious Disease, and within our facility specific Hazards Vulnerability Assessment (HVA). All aspects for the PEP can be located within our Emergency Management Plan (EMP).

Chapter 114 of the Laws of 2020:

Section 2803 of the public health law is amended by adding a new subdivision 12 to read as follows:

12. (a) each residential health care facility shall, no later than Ninety days after the effective date of this subdivision and annually thereafter, or more frequently as may be directed by the commissioner, prepare and make available to the public on the facility’s website, and immediately upon request, in a form acceptable to the commissioner, a pandemic emergency plan which shall include but not be limited to:

The Chestnut Park PEP was submitted initially to NYS DOH on Tuesday, September 15^th of 2020. This plan along with our facility EMP will be reviewed annually and more frequently if necessary. The Administrator and/or designee are responsible for this.

12. (I) a communication plan:

to update authorized family members and guardians of infected residents at least once per day and upon a change in a resident’s condition and at least once a week to update all residents and authorized families and guardians on the number of infections and deaths at the facility, by electronic or such other means as may be selected by each authorized family member or guardian;Our communication team is comprised of our RN UMs, Administration, Social Work Team, MDS Team and Nurse Management. This team will place a phone call to family members and/or guardians of infected residents detailing the aforementioned information located in section 12(I) (a).Chestnut Park also can utilize a “robo call” system that we have in place called ‘Text em all’. Family and guardian information is updated with the ‘Text em All’ system and is overseen by the Administrator. This system allows for us to make phone calls (messages) to families/guardians via mass calling. This system will and can be used in place of our communication team.

Social Media outlets can and are also utilized to inform our family members/guardians and the public. Facebook is our main social media source that is overseen by the Administrator. Our website provides a link for visitors to access and view our Facebook page for real time information.

and (b) that includes a method to provide all residents with daily access,

At no cost, to remote videoconference or equivalent communication methods with family members and guardians; and

Residents are able to retrieve electronic daily access to any information under 12(I) (a) using tablets to access our Facebook page or website. Information is also disseminated via letters/memos addressed to them.
- Chestnut Park has multiple tablets (IPad, Kindles, IPhone, etc.) for resident use for videoconferencing. These tablets are used for therapeutic relief but also to video conference/chat with their families/guardians at no cost. We have a facility Skype account to allow for video conferencing if the family member/guardian does not have an apple (IPhone/IPad) product.
- For scheduled care conference meetings family is invited to join remotely by videoconference, this is handled and scheduled by the social work team.
- All videoconference calls can and are set up by our social work, activities, and concierge team members if residents need additional help and oversight.
- Chestnut Park ’ “Communication during COVID-19 & other Infectious Disease” policy is updated and revised to reflect 12(I) (a) and (b) regulations. Our COVID-19 Action Plan is also updated routinely as regulations revise.

(ii) protection plans against infection for staff, residents and families, including:

a plan for hospitalized residents to be readmitted to such residential health care facility after treatment, in accordance with all applicable laws and regulations;A plan is in place and established for hospitalized residents to be readmitted to Evergreen after treatment, in accordance with all applicable laws and regulations. Same procedure and responsibilities as detailed with our “Bed Hold” policy will be followed for any resident that had an infectious and/or communicable disease. The purpose of this is to ensure bed availability upon return to the facility from a short hospitalization or therapeutic leave. The Admissions Director is responsible for this.

and

a plan for such residential health care facility to maintain or contract to have at least a two-month supply of personal protective equipment;Chestnut Park at the minimum will have at least a two-month supply of personal protective equipment (PPE) on hand, if not more at all times.Our PPE burn rate was and is routinely calculated through our facility specific daily HERDS and our weekly CDC submissions; this has been on-going since 3/2020. Central Supply is responsible for logging in and out all PPE, the organization of the PPE and for ordering when in need, timely.Our corporate office (USG), along with the facility Administrator oversee all PPE supply and ordering from various vendors to ensure our staff and residents are effectively and appropriately protected and are provided with the PPE resources they need.PPE is securely stored on-site within the facility and an additional 20 ft. secure storage trailer is on property, in the back of the facility, for an additional means to access a larger supply.

and

A plan for preserving a resident’s place in a residential healthcare facility if such resident is hospitalized, in accordance with all applicable laws and regulations. As aforementioned in 12(ii) (a); a plan is in place and established for hospitalized residents to be readmitted to Evergreen after treatment, in accordance with all applicable laws and regulations. Same procedure and responsibilities as detailed with our “Bed Hold” policy, which was revised to fit the necessary regulation, it will be followed for any resident that had an infectious and/or communicable disease. The purpose of this is to ensure bed availability upon return to the facility from a short hospitalization or therapeutic leave. The Admissions Director is responsible for this.

The residential health care facility shall prepare and comply with the pandemic emergency plan. Failure to do so shall be a violation of this subdivision and may be subject to civil penalties pursuant to section twelve and twelve-b of this chapter. The commissioner shall review each residential healthcare facility for compliance with its plan and the applicable regulations in accordance with paragraphs (a) and (b) of subdivision one of this section. within thirty days after the residential health care facility’s receipt of written notice of noncompliance such residential healthcare facility shall submit a plan of correction in such form and manner as specified by the commissioner for achieving compliance with its plan and with the applicable regulations. The commissioner shall ensure each such residential healthcare facility complies with its plan of correction and the applicable regulations.The commissioner shall promulgate any rules and regulations necessary to implement the provisions of this subdivision. § 2. This act shall take effect immediately.

Additional measures taken and in place under

Annex E: Infectious Disease/Pandemic Emergency Checklist Tasks:

Text Box: Please see facility COVID-19 Action Plan within Administration as guidelines and regulations revise often.
Full house education on infectious diseases etc. and Emergency Management Planning will take place at the minimum, annually, and more frequently if necessary.
All infection control and prevention policies are routinely reviewed, at the minimum, annually.
Per executive order, COVID staff testing is conducted as necessary, routinely for un-boosted and eligible employees, during outbreaks, and in conjunction with our county positivity rates. Our partnered lab runs all staff tests and results are uploaded into a portal system. We have a PCR device that allows for rapid testing for COVID-19 if necessary and we also utilize rapid/antigen tests that we have on-site. Effective 6/10/21 fully vaccinated staff no longer needs to be tested routinely. Necessary surveys are submitted appropriately per regulation to NYS DOH.
HCS system titles are reviewed routinely and back up (ICS/2nd in Command) plans in place to allow for timely reporting. See EMP.
PEP plan in place, central supply is in charge of stocked medications, cleaning agents, and PPE in conjunction with our pharmacy and other vendors. Safety Committee Meeting meets monthly and central supply logs done daily on the above. See Infection Control policy for stock-pile/emergency supply details.
Visitation policy is updated routinely, in real time as things change. Staff coverage and contingency plans can be found within our Emergency Management Plan (EMP) and are discussed weekly in our staffing committee as well as other HR issues. For any changes to our visitation policy or acceptance of admissions etc. our Communication policy will go into effect.
Environmental Controls are reviewed routinely and monthly as an interdisciplinary team (IDT) within safety meeting. Each unit has specific areas that are labeled properly for contaminated waste.

All vendor contracts are reviewed and/or revised on an annual basis or more frequently, if needed and can be found within our EMP, specifically but not limited to pharmacy, cleaning agents and PPE vendors.

“Room Transfers for Co-horting Purposes – Covid-19” policy is in place. Given the high risk of spread once COVID-19 enters a LTCF, facilities must act immediately to protect residents, families, and staff from serious illness, complications, and death. One of the measures to contain and minimize the spread of Covid-19 is to cohort similar residents and conduct room changes/transfers proactively. Designated floor plans are detailed within the EMP.

Communal dining and activities may be suspended during COVID-19 outbreaks; communication of this will be relayed.

Our recovery plan will be dependent and in conjunction with NYS DOH, CDC and CMS guidelines and regulations. Compassionate care/end of life visitation regardless of COVID-19 status will be afforded to visitors. When any new information is received our communication plan will go into effect to notify staff, residents, families, vendors, and stakeholders.

Communication detailed above on page 1 & 2. Our Communication during COVID-19 & other Infectious Disease policy including our COVID-19 Action Plan is up to date and continues to be revised as needed. This was completed as an IDT. CMS and CDC Transparency: Resident and Family Notification, DOH and other notifications educated at the minimum annually to our communication team and staff.

Protection Plan for residents, staff and families is in place and detailed above on page 2.

All current guidance is disseminated to residents via letters/memos. Families are notified via phone calls or video conferencing, we have the ability to also notify electronically via our social media page, Facebook, our website and through email if applicable. Advisories on visitation are posted on the front of our main doors. See our COVID-19 Action Plan.

All reporting requirements will be upheld and all staff to be educated at hire and annually within our Infection Control education and as needed.

Evergreen’s PEP was made available September 15, 2020 on our facility’s public website, and revised on June 16, 2021 and then again June 8, 2022. The PEP can also be located within administration upon request.

Our communication team is comprised of our RN UMs, Social Work Team, Administration, MDS Team and Nurse Management. This team will place a phone to family members and/or guardians of infected residents detailing the aforementioned information located in section 12(I)

(a). To update authorized family members and guardians of infected residents at least once per day and upon a change in a resident’s condition and at least once a week to update all residents and authorized families and guardians on the number of infections and deaths at the facility, by electronic or such other means as may be selected by each authorized family member or guardian; Chestnut Park also can utilize a “robo call” system/software that we have in place called “Text-Em-All”. Family and guardian information is updated with the ‘Text-Em-All” system and is overseen by the administrator. This system allows for us to make phone calls and messages to families/guardians via mass calling. This system will and can be used in place of our communication team. Social Media outlets can and are also utilized to inform our family members/guardians and the public. Facebook is our main social media source that is overseen by the Administrator. Our website provides a link for visitors to access and view our Facebook page for real time information. See “Communication & other Infectious Disease during COVID-19” policy.

Residents are able to retrieve electronic daily access to any information under 12(I) (a) using these tablets to access our Facebook page or website. Information is also disseminated via letters/memos addressed to them.

Chestnut Park has multiple tablets (IPad, Kindles, IPhone, etc.) for resident use for videoconferencing.

These tablets are used for therapeutic relief but also to video conference/chat with their families/guardians at no cost. We have a facility Skype account to allow for video conferencing if the family member/guardian does not have an apple (IPhone/IPad) product. For scheduled care conference meetings family is invited to join remotely by videoconference, this is handled and scheduled by the social work team. All videoconference calls can and are set up by our social work, activities, and concierge team members if residents need additional help and oversight. Chestnut Park ’ “Communication during COVID-1 & other Infectious Disease” policy has been updated and revised on 9/8/2020 to reflect 12(I) (a) and (b) regulations.

A plan is in place and established for hospitalized residents to be readmitted to Evergreen after treatment, in accordance with all applicable laws and regulations. Same procedure and responsibilities as detailed with our “Bed Hold” policy, that was revised to fit this regulation, will be followed for any resident that had an infectious and/or communicable disease. The purpose of this is to ensure bed availability upon return to the facility from a short hospitalization or therapeutic leave. The Admissions Director is responsible for this.

PEP Written and Submitted by:

Jeni Demarais, LNHA