25 Willett St, New York, NY 10002

Pandemic Emergency Plan

Read Our Pandemic Plan below or Download

 The plan will be reviewed at least annually by the facility Administrator and updated as often

required by state/federal regulations.

Introduction: Infectious diseases are caused by pathogenic microorganisms, such as bacteria,viruses, parasites, or fungi. The circumstances of infectious disease emergencies vary by multiple factors, including type of biological agent, scale of exposure, mode of transmission and intentionality. In the event of an actual or potential, local or regional infectious pandemic disease, the facility will implement the following plan to reduce the risk of exposure and spread to our residents, families, and staff.

Purpose: To guide facility leadership and staff on how to prepare for new or newly evolved Infectious diseases whose incidence in humans has increased or threatens to increase in the near future and that has the potential to pose a significant public health threat and danger of infection to the residents, families and staff of the facility.

Definition: A pandemic is a sudden infectious disease outbreak that becomes very widespread and affects a whole region, a continent, or the world due to a susceptible population. By definition, a true pandemic causes a high degree of mortality.

Policy: The facility’s Pandemic Emergency Plan (PEP) policy and procedure is part of the facilities overall emergency operations and preparedness plan. The Pandemic Emergency Plan policy includes specific state (NYSDOH) and federal (CDC and CMS) required actions including reporting of outbreaks/cases, infection control processes, staffing, acquisition and maintenance of personal protective equipment (PPE) supplies and stores as well as family and public communication. Additional guidance is provided in the facility’s emergency management plan.

All departments within the organization will be responsible for implementing the protocols within the plan. 

The plan will be reviewed at least annually by the facility Administrator and updated as often required by state/federal regulations.

Approval and Implementation

  • Administrator:  Corrado Mastropierro Date:  9/15/2020
  • Director of Nursing : Karla Zaldivar Date:  9/15/2020

Date Reviewed/Approved by Section Updated

8/12/2021 C.MASTROPIERRO Emergency Contacts

8/9/2022 C.Mastropierro Emergency Contacts

Preparedness: The facility will maintain preparedness for potential pandemic and/or infection outbreaks through:

  • Working with advice from the facility’s medical director, Director of Nursing, Infection Control Practitioner, local and state public health authorities, and others as appropriate, the facility will review and revise internal policies and procedures, have sufficient stock of medications, environmental cleaning agents, and personal protective equipment as necessary.

  • Enforce infection prevention, control, and reporting policies.

  • Develop administrative controls (e.g., visitor policies, employee absentee plans, human resource issues for employee leave).
  • Develop administrative controls (e.g., visitor policies, employee absentee plans, human resource issues for employee leave).

  • Develop procedures to ensure timely communications with resident families/designee.

  • Establish mechanisms that provides all residents with daily access to free remote video conferencing, or similar communication methods, with authorized family members and guardians.

  • Develop environmental controls (e.g., areas for contaminated waste).
  • Maintain 60-day supply of personal protective equipment including: surgical masks, gloves, gowns, face shields, surface, and hand sanitizing agents.
  • Develop vendor supply plan for re-supply of food, water, medications, PPE supplies, and cleaning/sanitizing agents.
  • Provide staff education on hire and at least annually on infectious diseases (e.g., exposure risks, symptoms, prevention, and infection control, use of personal protective equipment).

Emergency Contacts

Director of Nursing


Medical Director CHARLES KNOLL
Infection Control and PreventionistKARLA ZALDIVAR
Director of Facilities Maintenance ANTHONY PICCIURO
Director of Housekeeping/Laundry 


NYSDOH Regional Office212-417-4999 SHAWN DUDLEY
NYSDOH State Office
Local Office of Emergency ManagementDANIELLE SOLLICITO
Local Fire Department212-628-2900
Local Police Department212-477-7671
Regional Hospital/HospitalsBETH ISRAEL MOUNT SINAI

Activation/Response for Pandemic Emergency



  • The Administrator will implement the Pandemic Emergency Plan policy and procedures immediately upon notification from Federal, State or Regional NYSDOH declaration.

  • The Administrator, Director of Nursing and Infection Control Preventionist will obtain guidance from the NYSDOH and the U.S. Centers for Disease Control and Prevention on disease-specific response actions and implement appropriate infection control policies and procedures, notifications, and any appropriate/required education.  
  • The Infection Control Practitioner will clearly post signs for infection prevention including but not limited to cough etiquette, hand washing, and other hygiene measures in high visibility areas and will determine necessity of providing hand sanitizer and face/nose masks, if practical.
  • As necessary, administration will close facility to new admissions and limit visitors when there are confirmed cases in the community.
  • Advise staff to observe for signs and symptoms of illness and not to report to work if sick. If necessary, activate surge staffing strategies.

Notification and Reporting 

  • Internal: 
    • The administrator will announce and provide education to leadership staff on the nature and scope of the pandemic situation based on the information available and the cases identified within the facility.  
    • The facility will contact all staff, vendors, other relevant stakeholders on the facility’s policies and procedures related to minimizing exposure risks to residents.
  • External Notification:  
    • The Incident Commander will initiate and designate specific staff to establish and maintain communication to the following entities as per federal (CMS) and state (NYSDOH) regulation:
      • NYSDOH: Any outbreak or significant increase in nosocomial infections above the norm or baseline in nursing home residents or employees will be reported electronically to the NYSDOH through the Health Commerce System’s Nosocomial Outbreak Reporting Application daily (or as directed) on the number of new cases.
        • See Infection Outbreak Policy for additional information on reporting requirements
  • Families/Residents/Ombudsman:
    • The facility will provide residents, relatives, and friends with education about the disease and the facility’s response strategy at a level appropriate to their interests and need for information. 
    • The Administrator will direct appropriate signage and notifications to all staff, residents, family/designee, vendors and Ombudsman regarding interruptions or changes to onsite visitations as directed by the NYSDOH to reduce exposure risk to residents. 
    • All authorized family members and guardians of residents infected with the pandemic infectious disease will be updated at least once per day and upon a change in the resident’s condition by electronic means or other method selected by each family member or guardian
    • All residents and authorized family members and guardians will be updated once per week on the number of infections and deaths at the facility; by electronic means or other method selected by each family member or guardian
    • Notify residents and families of procedures to provide daily access to free remote videoconferencing, or similar communication methods, with authorized family members and guardians. 

Facility and Incident Command PEP Response Rolls and Responsibilities: 

(Note: Roles may vary dependent on needs of facility, extent of pandemic and staffing)


  • Determines appropriate staff to fill all incident command roles.  
  • Meets with command staff to establish roles, reporting structure and assessment needs.  
  • Directs Documentation recorder and reviews all documentation to determine intent of all meeting minutes, notations, and files for designation as for Quality Assurance purpose, Attorney/Client Privilege, DOH/Public Entities and/or media/family/resident release.
  • Reviews Health Commerce System at least daily for DOH and/or DAL and update leadership staff accordingly


  • DON will review policies and procedures for infection control and outbreak.  
  • Expedite education to all staff on infection prevention, outbreak control including appropriate use don/doff PPE.  
  • With Director of Housekeeping and Facilities Maintenance review all infection prevention, laundry,and deep cleaning policies and procedures. 
  • Direct Director of Housekeeping to project need for additional infection control cleaning.  

Logistics/Central Supply:

  • Assess to ensure the 60-day supply of PPE as required has been maintained, if not, logistics will immediately assess supply and procure.  
  • Supplies to be maintained include, but are not limited to:
    • N95 respirators
    • Face shield,
    • Eye protection
    • Gowns/isolation gowns – disposable and re-usable
    • Gloves
    • Masks – surgical and N-95
    • Sanitizer and disinfectants in accordance with current EPA and NFPA use and storage guidance

  • With Operations, logistics will identify the number of current and expected/projected cases (specifically new admission and newly diagnosed/inhouse) and calculate burn rate for PPE
  • With Operations, logistics will identify and procure additional materials needed for surface and/or equipment cleaning and air filtration 


  • Will meet with Management of Facility and staffing and review current clinical and non-clinical staffing to projected needs, potential shortages and implement surge staffing as directed
  • Review with Operations and Employee health staff all policies and procedure for staff testing, removal/tracing and return to work policies.
    • See Employee testing and Return to work policy   
  • Establish nursing and non-nursing volunteers for overtime if possible/available.
  • Establish non-nursing staff availability to assist with resident care related tasks including:
    • Bed making
    • Feeding
    • General Supervision and/or Recreation
  • Establish/update nursing agency staffing communications and/or contracts and their ability to provide immediate assistance.  
  • Training:
    • Review current training programs and ability to expand or utilize existing waivers for training to increase work force. 


  • Review current operations budgets including staffing and materials/supply as well as any constraints with Administration
  • Develop lines of credit as needed with supply vendors
  • Review for any available public or private grants/loans


  • The Public Information Officer will designate and educate staff on daily reporting requirements for NYSDOH HCS. 
  • Public Information Officer will designate (social service/case management staff) to identify and document in the resident’s medical record the method of how each resident’s authorized family member wishes to receive regular communication.  
  • The Public Information Officer will designate a staff member to update the authorized family members and guardians of residents infected with the pandemic infectious disease at least once per day and upon a change in the resident’s condition.  The communication will then be documented in the resident’s medical record. 
  • The Director of Recreation shall continue video conferencing access for residents.

  • The Public Information Officer will designate (Social Service and Recreation Staff) to identify and document those residents and/or authorized representatives that wish to establish visitation via video conference visits and establish a schedule for each on a daily basis or as requested.  

Additional Protective Actions /Infection Control for Pandemic Emergency:  

Recognition and preparedness of accepting and implementing proper procedures for community associated infections is critical to provide appropriate medical and nursing care to new admissions or in the event a resident is hospitalized for the pandemic infections disease and prevent the spread of communicable, contagious, or infectious diseases.  


  • In the event of a Pandemic Emergency, the facility may determine it is necessary to close to new admissions to protect the residents of the facility.  
  • In the event that a resident of the facility is hospitalized for the pandemic infection, the facility will re-admit those residents in compliance with all state and federal requirements including but not limited to 10 NYCRR 415.19, 415.3(i)(3)(iii) and 415.26(i); and 42 CFR 483.15(e).  
    • (See Admission/Re-admission Policy for Infectious Disease additional information- note policy subject to change based on CDC and DOH updates) 


  • Any resident upon admission or re-admission to facility that is suspected of or having been diagnosed with the pandemic disease or as having a communicable, contagious, or infectious disease will be isolated and placed on appropriate precautions per CDC guidelines and facility Infection Control Policy.  
  • If more than one resident is identified with the communicable disease the facility will institute its Outbreak Control policy (See Outbreak Control Policy).  
  • The facility will isolate and/or cohort residents based on CDC guidelines for Isolation /Precautions including but not limited to discontinuing any sharing of a bathroom with residents outside the cohort; dedication specific group of rooms, specific unit/hallway or wing.  
  • Demarcating/Signage:  The facility will also ensure that the areas of isolation/quarantine dedicated to these infectious residents are demarcated and have adequate signage to ensure proper identification and reminders for healthcare personnel.  

Discharge:  In the event that the facility determines that a residents with a pandemic related communicable diseases cannot be cared for properly, cannot be cohorted/isolated per regulation or that the facility can no longer sustain cohorting efforts, the facility will notify the regional and local Department of health offices as well as the designated representative and the resident(s) will be transferred as soon as possible to a facility that can properly treat such diseases. 


Upon NYSDOH notification the facility will discontinue Pandemic Emergency Plan.  

Administration will notify staff, residents, families, community partners/vendors and Ombudsman of the facility plan to begin resumption of normal operations.  

Administration/Leadership will conduct analysis of the Pandemic Emergency and the facility response/actions.  Analysis may include but not limited to issues related to disruptions in operation, supplies/supply chain, financial ramifications, staffing as well as psycho-social impacts to residents as well as staff.  Administration will determine appropriate responses and strategy implementation and document in the After-Action Summary.   

Demobilization and Infrastructure Restoration

Upon NYSDOH notification and determination by administration, the facility will take appropriate steps to ‘demobilize’ and resume normal operations.  These areas include but are not limited to: 

  • Removal of signage and PPE stores
  • Deconstruct quarantine/isolation unit
  • Rooms/Areas serving Pandemic Related activities will be transitioned back to normal use.  
  • Re-integration of isolated residents into general population
  • Resumption of normal visitation and group recreational activities.  
  • Resumption of regular admission practices

Resumption of Full Services 

Upon notification by NYSDOH and determination by administration the facility will notify staff and vendors that normal operations including but not limited to:  

  • Facility repair and inspection, 
  • Resumption of resident care services including:
    • Hair Salon
    • Resident Outings
    • Other services
  • Pre-incident staff scheduling and  
  • Pre-incident equipment/supply inventory and inspection.  

Resource Inventory and Accountability

The facility will conduct an assessment of the inventory of all equipment, devices, and supplies needed to fully resume services following an incident and develop strategy to ensure appropriate response for future pandemic emergency.