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The Highlands Living Center
Pandemic Emergency Plan (PEP)

The Highlands Living Center’s Pandemic Emergency Plan is a comprehensive plan incorporating other detailed specific plans including, but not limited to, the Emerging Infectious Disease Response Plan, Emerging Infections Plan, Infectious Disease Cohorting Plan, Infection Prevention and Control Policy and Emergency Management Plan.

The Highlands Living Center shall provide staff education in accordance with Federal and State guidance and requirements including 10 NYCRR 415.3(i)(3)(iii), 415.19, and 415.26(i); 42 CFR 483.15(e) and 42 CFR § 483.80).   The Highlands Living Center shall develop and utilize an Interdisciplinary Pandemic team (Policy No.2.8 Infection Prevention and Control Policy)to provide direction on staff education including that on facility-wide infection prevention and infectious diseases; personal protective equipment (PPE); cleaning and disinfecting; guidelines for cohorting for specific infection prevention precautions and corresponding competencies as indicated.   This educational initiative shall include that information is relayed to staff when changes or revisions to policies and procedures occur and that formal education, coaching and mentoring is completed.   


The Highlands Living Center maintains an Emerging Infections Plan that includes reporting policies.   The policies are developed and reviewed by the Infection Control Team that includes the Medical Director, Administrator, Director of Nursing, Infection Preventionist and Occupational Health Nurse.  Updates to policies shall be developed and existing policies revised as appropriate and when indicated based on updates from the CDC, NYSDOH, and CMS.  Policies shall be effectuated and enforced subsequent to review and approval by the Infection Control Team. The Occupational Health Nurse shall be informed of employee absences for follow up and instruction consistent with Infection Control best practices.  Routine communication between administration and management staff shall be maintained to review and anticipate the facility’s operational needs.


The Highlands Living Center conducts routine, ongoing, infectious disease surveillance.  Policies include that appropriate infection prevention precautions shall be identified and implemented with appropriate PPE utilization.  All residents shall be routinely monitored on an ongoing basis for temperature, O2 saturation, respiration rate and symptoms every shift.  Infection Prevention and Medical Staff shall be notified of any abnormal findings. Line lists are to be maintained to track infectious illnesses allowing Infection Prevention to identify background rates to further detect when significant increases occur.


The Highland Living Center’s plan for staff testing and laboratory services including reporting requirements and monitoring systems, is developed by the Interdisciplinary Pandemic Team for implementation in compliance with guidance and regulatory requirements from the NYSDOH, CMS and CDC and revised as necessary.  The Highlands Living Center maintains an agreement with a commercial laboratory to provide required testing.    


The Highlands Living Center ensures adequate facility access to Communicable disease reporting tools and ensures that reporting occurs as required by the NYSDOH, CDC and CMS. This includes timely reporting on the Nosocomial Outbreak Reporting Application (NORA), NHSN (CDC) reporting, and reporting on the HERDS reporting system. The facility has designated a primary and secondary reporter responsible for reporting to ensure timely and consistent reporting. Reporting shall be directly overseen by Infection Prevention and Occupational Health Nurse and when appropriate in conjunction with the Medical Director and NYSDOH Epidemiologist.


The Highlands Living Center maintains and updates an Emergency Management Plan All Hazard Responses to amass necessary environmental cleaning agents and personal protective equipment as necessary.  The facility’s Interdisciplinary Pandemic Team including the Medical Director, Administrator, Director of Nursing, Infection Control Practitioner, Facilities Director and Director of Human Resources provide appropriate oversite ensuring involvement with local and state public health authorities, and others as appropriate.   A process is used to allocate PPE and sanitizing supplies as overseen by the Facilities Director with regular vendors, URMC supply chain and the Monroe County Office of Emergency Management when necessary.  Emergency medical supplies are maintained in emergency drug boxes.  The pharmacy service provider supplies maintains and supplies emergent medications to comply with all codes, rules and regulations.  


The Highlands Living Center’s Interdisciplinary Pandemic Team shall develop and implement policies specific to guidelines and regulations as specified by the NYSDOH, CDC and CMS, reviewing and updating as appropriate.   Screening tools and internal policies will be based on guidelines to include visitor policies, employee absentee plans, staff wellness and symptomology and human resource issues for employee leave


The Highlands Living Center maintains environmental controls including areas for contaminated waste in compliance with State and Federal codes, rules and regulations.  The Facilities Director reviews the Hazardous Regulated Medical Waste policy annually with revision as appropriate, and monitors to ensure compliance.  The facility maintains a contract with a Regulated Medical Waste vendor for compliant disposal and tracking.


The vendor supply plan is developed and revised as appropriate and overseen as appropriate by the Director of Fine Dining and the Director of Facilities who ensure that contractual agreements are maintained to meet the needs of the facility.  The plan includes monitoring of inventory, ensuring adequate procurement of goods and continual communication with vendors and URMC supply chain to meet pre-determined and ongoing facility needs. This includes food, water and other supplies and sanitizing agents.  The Director of Nursing and Pharmacy Consultant ensure appropriate and adequate supply of medications.  The Highlands Living Center uses the Emergency Management Plan applicable to Hazardous Responses.


The Highlands Living Center’s Infection Control Team develops and reviews regulations and guidance from the NYSDOH, CMS and CDC to ensure ongoing compliance and the implementation of best practices in isolating, cohorting, or transferring residents during an infectious disease event.  Policies are reviewed by the Infection Preventionist and Medical Director.  The facility’s Pandemic Cohorting plan details specific cohorting strategies and space designations, along with the isolation and infection prevention measures required.


The Highlands Living Center’s Pandemic Cohorting Plan includes the designation of a separate area of the facility which involves discontinuing any sharing of a bathroom with residents outside of the cohort.  The plan is specific and detailed.


The facility’s plan on social distancing measures were developed by the Interdisciplinary Pandemic Team with review and revision as appropriate to comply with the guidance and regulations of the NYSDOH, CDC and CMS.  The Interdisciplinary Pandemic Team is responsible to ensure that measures developed are appropriate to meet facility needs during a pandemic emergency including non-essential activities, dining arrangements for staff members and residents and common areas with signage as appropriate.


The Highland Living Center’s Interdisciplinary Pandemic Team will adhere to NYSDOH, CDC and CMS guidance and regulations in returning the facility to normal operations. The Highlands Living Center will utilize the Disaster Recovery Plan in accordance with the Emergency Management Policy in order to return to normal operations.  The facility Command Center will manage the recovery process though the use of the Incident Command System in compliance with NYSDOH, CDC and CMS instruction.   


The Highlands Living Center’s Pandemic Communication Plan was developed by the Interdisciplinary Pandemic Team to include all required elements of the Pandemic Emergency Plan for review and revision as needed. The areas covered in our plan include

  • providing staff with regular ongoing incident updates as necessary
  • providing media statements as necessary
  • Ensuring that appropriate external and internal notifications have taken place
  • Determining the need to contact the NYSHDOH, CDC, Department of Health and Human Services as appropriate
  • Developing, maintaining and updating a communication plan for residents and their families
  • Developing, maintaining and updating a communication plan to interact with other entities including but not limited to local responders and other healthcare facilities

Additional Preparedness Planning Tasks for Pandemic Events

The Highlands Living Center’s Interdisciplinary Pandemic Team developed plans for the protection of staff, residents and families against infection consistent with NYSDOH, CDC and CMS guidance and regulations for review and revision as appropriate.  This includes disease specific response actions as appropriate and Emerging Infectious Disease response. This plan includes but is not limited to the maintenance required supply of PPE that is securely stored, the appropriate education of staff members and implementation of PPE usage, screening and monitoring employees and visitors, and monitoring residents for symptoms with action taken as appropriate, cohorting residents as appropriate, cleaning and sanitizing measures meeting EPA guidance, implementing the plan for social distancing, and ongoing monitoring to ensure compliance with our plan.


The Highlands Living Center will implement the following procedures to obtain and maintain current guidance, signage, advisories from the NYSDOH and the U.S. Centers for Disease Control and Prevention (CDC) on disease-specific response actions, e.g., including management of residents and staff suspected or confirmed to have disease.   The Highlands Living Center’s Interdisciplinary Pandemic Team develops and reviews facility policies on best practice on disease specific response actions related to emerging infectious diseases and regularly reviews the newest guidance from the CDC, DOH and CMS to develop and revises policies and procedures for implementation including management of residents and staff suspected or confirmed to have disease. The Infection Preventionist is a member of the national infection prevention organization allowing an additional means of gaining regular, ongoing updates on best practice.


The Highlands Living Center assures that it meets all reporting requirements for suspected or confirmed communicable diseases as mandated under the 10 NYCRR 2.10 Part 2 as well as 10 NYCRR415.19 for reporting requirements, and reports to the NYSDOH any outbreak or significant increase in nosocomial infections above the norm or baseline conducting surveillance that is adequate to identify background rates and detect significant increases above those rates.  The nursing department maintains a line list and provides Infection Prevention with monthly HAI report. 


The Highlands Living Center shall meet all reporting requirements of the Health Commerce System, e.g. HERDS survey reporting.  Designated individuals are assigned as reporters to complete the HERDS survey seven days a week and a process has been developed to monitor and record staff census, staff testing results and PPE supply.  The reporter is responsible for gathering data and submitting on HERDS in a timely manner as required.

The Highlands Living Center’s Interdisciplinary Pandemic Team ensures that signage shall be clearly posted to ensure cough etiquette, hand washing, and other hygiene measures in high visibility areas.  Hand sanitizer (60% or greater) shall be readily accessible throughout the building for all.  Facemasks shall be provided and shall be required for all staff and visitors allowed in the facility.


Response Tasks for all Infectious Disease Events:

The Highlands Living Center shall implement procedures developed to limit exposure between infected and non-infected persons and consider segregation of ill persons, in accordance with any applicable NYSDOH, CDC and CMS guidance as well as facility policies. Implementation shall include The Highlands Living Center’s Emerging Infectious Disease Response, Infection Control Guidelines and Cohorting plan. These includes donning and doffing PPE as per competencies; monitoring for signs and symptoms of illness; immediate notification of medical and infection prevention staff; determination of resident infection status; environmental controls specific to disease specific infections. The Highlands Living Center ensures that infected residents are isolated-cohorted and or transferred based on their infection status in accordance with applicable guidance from the CDC, NYS local-state Health Departments.


The Highlands Living Center shall implement procedures to ensure that as much as possible separate staffing is provided to care for each infection status cohort and shall designates a distinct infection designated area consistent with NYSDOH, CDC and CMS guidance and regulations.  The Nursing Contingency Staffing policy shall be implemented as necessary. The facility is part of the Greater Rochester Mutual Aid Plan addressing surge. 


The Highlands Living Center has developed a disinfecting and sanitizing infection prevention program including daily rounds for cleaning and disinfecting all areas of the building and ensuring adequate PPE supplies and sanitizer is available for all staff and visitors as needed.  This is documented regularly, reviewed by the Director of Facilities and maintained on file by the Director of Facilities.  There is a policy for identifying infection status of residents with immediate notification to Environmental Services.  Cleaning practices are outlined in procedures for Infection Prevention and are implemented in identified infection rooms in accordance with the policy. The facility uses EPA, CDC and DOH guidance in development of cleaning and disinfecting of isolation rooms.


The Highlands Living Center provides updates daily on our website specific to Pandemic infections in compliance with NYSDOH and CMS regulatory requirements. Information for families educating them about the Pandemic infection at a level appropriate to their interest and need for information is provided on the website. The Highlands Living Center’s strategies for identifying infections and other measures taken to ensure the safety of residents and staff related to infection and prevention is included in this educational material. Specific procedures taken when a resident is positive for infection including notification to resident, families and NYSDOH are posted on the website for families, or mailed to families as per their request as per NYSDOH and CMS regulatory requirements. Residents obtain information on COVID and the facilities’ response strategy, including updated information on emerging infections through letters, eScreens display and in person notification provided by nursing and social work appropriate to that resident’s level of understanding.


The Highlands Living Center will follow the Pandemic Communication plan to contact all staff, vendors, other relevant stakeholders on the facility’s policies and procedures related to minimizing exposure risks to residents and to provide information regarding facility-maintained list of external stakeholders to be contacted and mechanisms for sharing this information. 


The Highlands Living Center, when appropriate and in accordance with applicable New York State Executive Orders and/or NYSDOH guidance, will implement procedures to close the facility to new admissions, limit visitors when there are confirmed cases in the community and/or to screen all permitted visitors for signs of infection.  The Highlands Living Center has developed policies for visitation consistent with regulatory requirements.  The visitation policy developed by the Interdisciplinary Pandemic team, shall maintain compliance with guidelines and regulations by the NYSDOH and CMS, as well as Governor’s Executive Orders, and will be reviewed and revised as necessary,.  The visitation policy will be communicated pursuant to The Highlands Living Center Pandemic Communication plan.  Such visitation shall ensure the safety of the residents and staff members.   Permitted visitors shall be screened at the main entrance of the building using a screen form that includes health status, exposure risk questions and out of state travel.  Each visitor shall be checked for fever, must use hand sanitizer, and shall be given a facemask to wear and instruction sheet on visitation expectations and social distancing.  


All staff are educated on Infection Prevention including the use of PPE.  Competencies are performed for donning and doffing. Procedures have been established and implemented by the Infection Control team to identify and communicate the infection status of residents and measures to be used related to PPE use. Procedures include the identification of isolation rooms using specific signage that specify PPE required.  Quality Assurance audits are conducted to ensure compliance including that proper PPE is available and appropriately in use.


The Highlands Living Center’s PEP will be posted on its website and a copy maintained at the Reception desk for immediate availability upon request.


The Highlands Living Center’s medical and nursing staff will notify the resident and family member or guardian of a resident’s diagnosis of a Pandemic related infection.  Daily communication as well as any change in resident condition will e communicated to the family by the nursing staff or medical provider by phone or another means of communication as requested by the family.


The Highlands Living Center’s Pandemic Communication plan will be followed to ensure that all residents and authorized families and guardians are updated at least once a week on the number of pandemic related infections and deaths at the facility, including residents with a pandemic related infection who pass away for reasons other than such infection. This plan includes that the website and eScreens (in the building)are updated daily on the number of Pandemic related infections and deaths including residents infected with a pandemic related illness who pass away for other reasons than such infection.

The Highlands Living Center’s Pandemic Communication plan includes Wi-Fi capability for resident access and electronic equipment (laptops, iPads and iPhone) for residents who do not have their own for access to Wi-Fi, seven days a week.  Procedures are established  for Recreation to assist residents and develop schedules for residents and family communication.


The Highlands Living Center’s Admissions Policy  complies with all state and federal codes, rules and requirements on admission and readmission practices including but not limited to 10 NYCRR 415.3(i)(3)(iii), 415.19, and 415.26(i); and 42 CFR 483.15(e).  All residents admitted and readmitted from the hospital or any other setting are screened and reviewed by the Admissions Manager to ensure appropriate and safe placement. 


The Highlands Living Center’s bed reservation policy complies with Federal  and State regulations on bed hold and therapeutic leave practices s including but not limited to 18 NYCRR 505.9(d)(6) and 42 CFR 483.15).  This policy is given to the resident and his representative at the time of admission, upon discharge or transfer and a copy of the bed reservation notification form with noted bed hold determination is placed in the resident record with the original notification form either given to or mailed to the resident or appointed designated resident. Residents whose hospitalization exceeds the bed period under the NYS plan may be readmitted immediately upon the first appropriate semi private bed available, if the resident requires the services provided by the facility and is eligible for Medicare skilled nursing facility service or Medicaid nursing facility service.  If a resident is private pay, the Social Worker contacts the resident or appointed designated representative to ascertain whether the bed is to be reserved at the private pay per diem rate.


The Highlands Living Center’s planned procedures includes maintaining or contracting to have at least a two-month (60-day) supply of personal protective equipment (including consideration of space for storage) or any superseding requirements under New York State Executive Orders and/or NYSDOH regulations governing PPE supply requirements executed during a specific disease outbreak or pandemic. 

The process used to maintain adequate supplies of at least a two month, 60 day supply of PPE( n95 respirators, face shields, eye protection, gowns, gloves, masks, sanitizer and disinfectants) includes ordering from contracted vendors, non-contracted vendors, URMC purchasing supply chain, URMC affiliates and when necessary through contact with the Monroe County Office of Emergency Management.

An inventory is maintained by the central supply with regular reports to the Infection Control Team. PPE is stored both on-site and off-site (allowing for large quantities of readily accessible PPE for which storage is difficult to maintain onsite). 

The off-site stored PPE is located in Rochester, NY, and the trigger point is identified as being when the facility stored PPE is below a 45 day supply level.  This allows ample time to cover processing and approval as well as delivery and loading/unloading of supplies.


The Highlands Living Center 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 Highland Living Center’s Disaster Recovery Plan will be used in conjunction with the regulatory guidance issued at the time of the specific pandemic event.


The Highlands Living Center’s Pandemic Communication plan includes communication of any relevant activities regarding recovery/return to normal operations.  The plan includes communication, with staff, families/guardians and other relevant stakeholders.

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