Background & Lessons Learned:

Foothill Acres Rehabilitation & Nursing Center, as many other nursing centers, has experienced the heartbreaking impact of the COVID-19 pandemic. Living in a healthcare setting brings inherent risks due to the vulnerability of the residents we care for and the communal lifestyle. Our efforts to provide a homelike environment that promotes independence and person directed care, can contribute to the spread of a respiratory infection such as COVID-19 when aggressive restrictions are not implemented early in the
outbreak. Finding a balance between the need to be aggressive and honoring the basic rights of our residents and families will require a comprehensive plan that includes methods to communicate with residents, visitors and the staff so we can all work together to limit the exposure and to prevent the spread of respiratory infections including COVID-19.

POLICY:

Foothill Acres Rehabilitation & Nursing Center has developed a comprehensive response plan to address the global pandemic due to COVID-19. The plan will be in place to protect the residents, staff and visitors from respiratory infections including COVID-19.

PROCEDURE:

•  The facility will create a COVID-19 Committee team consisting of the following:
  Medical Director: Dr. Richard Corson
  Administrator: Pinny Goldblatt
  Director of Nursing: Diana Truelove
  Asst. Director of Nursing: Ariel Rante
  MDS Coordinator: Linji Li
  Rehab Director: Umang Shah
  Social Service Director: Ellen Schwartz
  Admissions Director: Steve Aksim
  Maintenance Director: Jason Toifel
  Activities Director: Mary Walaszek /
  Nancy Guerrera
  Housekeeping Amaury Sanchez
  Dietary Director: Gary Koch
  Dietician: Jessica Hanna
  Pharmacy Representative: Ann Santos
  Laboratory Representative: Thomas Bejgrowicz
• The facility’s COVID 19 Response Coordinator will be: Pinny Goldblatt, Administrator.
• The facility will coordinate with the transport company if a presumptive or confirmed COVID-19 is going to be transported. Face mask will be provided to the resident for transport to protect the transport staff and receiving facility staff.
• The facility physician will coordinate with the receiving facility’s physician to ensure report is accurately communicated and precaution is in place.
• Dedicate equipment in isolation rooms. If not possible, clean and disinfect equipment using the EPA- registered disinfectant before use with another resident within the cohort.
• Conduct routine cleaning and disinfection of high touch surfaces and shared medical equipment using EPA-registered disinfectant.
• Increase frequency of routine cleaning and disinfection.
• Prioritize rounding in a “well to ill’ flow to minimize cross-contamination.

Communication with Residents and Families:

POLICY:

It is the policy of this facility to inform residents, their representatives, and families of the residents by 5pm the next calendar day following the subsequent occurrence of either: each time a single confirmed infection of COVID-19 is identified or whenever three or more residents or staff with new-onset of respiratory symptoms occurs within 72 hours of each other.

PROCEDURE:

1. Nursing Administration will notify the Administrative Staff if the facility meets either of the criteria listed above. The Administrative Staff will gather all required information as directed in CMS rule: 42 CFR 483.80(g) and with CMS guidance at https://www.cms.gov/files/documents/gso-20-29-nh.pdf.
2.  Administrative Staff will send required information out via email and text to all residents, their representatives, and families of the residents by 5pm the next calendar day following the subsequent occurrence of either: each time a single confirmed infection of COVID-19 is identified or whenever three or more residents or staff with new-onset of respiratory symptoms occurs within 72 hours of each other.
3.  Residents will be notified of a new outbreak via our closed circuit television system which will be posted by 5pm the next calendar day following the subsequent occurrence of either: each time a single confirmed infection of COVID-19 is identified or whenever three or more residents or staff with new-onset of respiratory symptoms occurs within 72 hours of each other.
4. The required information along with an emergency number for urgent calls and complaints will be posted on our website by 5pm the next calendar day following the subsequent occurrence of either: each time a single confirmed infection of COVID-19 is identified or whenever three or more residents or staff with new-onset of respiratory symptoms occurs within 72 hours of each other.
5. Administrative staff will continue to send out information to all residents, their representatives, families and employees at least once weekly for any facility updates.
6. Foothill Acres will also be providing weekly conferences on a scheduled basis for all who like to attend. Scheduled calls will be posted on facility’s website and/or social media along with e-mail address will be made available to all residents, their representatives, families and employees for any urgent issues or concerns that may need immediate attention.

Communication with Employees:

POLICY:

It is the policy of this facility to inform all employees by 5pm the next calendar day following the subsequent occurrence of either: each time a single confirmed infection of COVID-19 is identified or whenever three or more residents or staff with new-onset of respiratory symptoms occurs within 72 hours of each other.

PROCEDURE:

1. Nursing Administration will notify the Administrative Staff if the facility meets either of the criteria listed above. The Administrative Staff will gather all required information as directed in CMS rule: 42 CFR 483.80(g) and with CMS guidance at https://www.cms.gov/files/documents/gso-20-29-nh.pdf.
2.  Administrative Staff will send required information out via email and/or text to all employees by 5pm the next calendar day following the subsequent occurrence of either: each time a single confirmed infection of COVID-19 is identified or whenever three or more residents or staff with new-onset of respiratory symptoms occurs within 72 hours of each other.
3. Should an employee refuse to provide the facility with a means to contact them via email and/or text then it is the responsibility of the employee to reference the website where the information will be posted by 5 PM the next calendar day.
4. The required information along with an emergency number for urgent calls and complaints will be posted on our website by 5pm the next calendar day following the subsequent occurrence of either: each time a single confirmed infection of COVID-19 is identified or  whenever three or more residents or staff with new-onset of respiratory symptoms occurs within 72 hours of each other.
5. Administrative staff will continue to send out information to all residents, their representatives, families and employees at least once weekly for any facility updates.
6. Foothill Acres will also be providing weekly conferences on a scheduled basis for all who like to attend. Scheduled calls will be posted on facility’s website and/or social media along with e-mail address will be made available to all residents, their representatives, families and employees for any urgent issues or concerns that may need immediate attention.

General Facility Control Measures

• Establish testing capacity to identify SARS-CoV2 through RWJUH Somerset Laboratory and ACULABS Laboratory to conduct test, and provide appropriate specimen collection materials.
• Ensure sufficient supply of Hand Hygiene resources in the facility.
• Evaluate personal protective equipment (PPE) and report level to corresponding
  agency/OEM/LDOH/NJDOH.
• Educate staff on infection prevention practices, control measures for COVID-19.
• Facility will implement Universal Source control by providing facemask to person in the facility. As an alternative, cloth mask will be provided in the event of supply shortage for staff that does not provide direct care to the residents.

Daily Reporting

• Complete line listing for residents / staff.
• Submit line listing to Hillsborough Township Health Department per instruction. Hillsborough Township Health Department representative Siohban Spano.

Admission, Transfer and Readmission

• Close the unit affected to new admissions except as needed to cohort individuals and staff.
• Consider closing to new admissions if the facility is unable to appropriately cohort. This does not include readmission back to the facility.
• When transferring a resident to another facility / hospital, transporting company will be informed of the Transmission Based Precaution in place as well the as receiving facility.
• New admissions and readmissions will be monitored for signs of COVID-19 for 14 days and will be cared for by staff using COVID-19 PPE (N95 or Respirator, eye protection, gloves and gown). They will be placed in private rooms (if available). If feasible, a cohort will be created for this population.

Emergency Staffing Strategies:

POLICY:

In the event of an emergency, the Administrator or DON will make the decision to utilize emergency staffing strategies as necessary to provide for care and treatment of residents.

PROCEDURE:

1. All employees in the facility will be notified of the decision to utilize emergency staffing strategies.
2. In the event the facility has difficulty with staffing the facility in an event of an emergency, the following will take place:
   a. Remove tasks from the nursing department that does not need to be completed by a CNA or Nurse including but not limited to passing out water, answering call bells, passing out snacks and meal trays to alternate employees.
   b. Restorative nursing staff will assist on the units as well as Rehab staff within their scope of practice
   c. Nursing Administration (DON, ADON, Unit Manager and Supervisors) may need to work on the units as needed
3. Dietary department may utilize paper products in order to free staff to assist in other areas.

Virtual Communication:

POLICY:

To continue to provide the vital opportunity for family members to interact with their loved ones while minimizing the chance of the spread of COVID-19.

PROCEDURE:

• Scheduling for all video chats will be done by the Activity Department.
  o All family members were notified to send an email for all virtual visitation requests to
  foothillacrescommunication@gmail.com at least 24 hours prior to requested video chat time.
  o Email addresses for new admissions are obtained by Admissions and/or Receptionist.
  o Chats are scheduled daily from 10:00 am to 7:00 pm and are limited to 10 minutes.
  o A daily schedule will be printed and distributed to each unit and Activity Supervisor so everyone knows what chats are scheduled for the day.
  o Activity Director and/or Activity Supervisors will coordinate who will be assigned to carry out each video chat scheduled.
    – On units with suspected or confirmed COVID-19 or 14-day quarantine, the Activity
  Supervisor or Director will coordinate with Unit Managers to identify any residents that
  could done by Nursing staff while in the rooms.
  o When video session is complete, staff are to log the results and notify Activity Director or Supervisor of any issues during the call.
• For units/rooms with no confirmed or suspected cases of COVID-19 or residents on 14-day quarantine:
  o Activity staff or other facility staff will complete video chats with residents.
  o All tablets and iPads will be wiped down with disinfecting wipes before and after each use.
  o If resident has difficulty hearing, there are headphones with a mic available for that resident to use and keep at their bedside. Headphones will be labeled with the resident’s name on them.
• For units/rooms with at least 1 confirmed or suspected case of COVID-19 or residents on 14-day quarantine:
  o All tablets and iPads will be wiped down with disinfecting wipes before and after each use.
  o All tablets and iPads will be placed in a gallon zip lock bag prior to entering the resident room.
  o Staff will don all appropriate PPE prior to entering room.
  o Stands for devices are available for use to promote social distancing once virtual call has been established. Stands must be wiped down before use.
  o If resident has difficulty hearing, there are headphones with a mic available for that resident to use and keep at their bedside which will be labeled with the resident’s name on it.
  o Dispose of zip lock bag when video chat is complete and wipe down tablet and stand with disinfecting wipe.
  o Activity staff will complete video chats for residents who are not confirmed with COVID-19 or showing any symptoms. To minimize the traffic in an isolation room, the CNA or other nursing staff may complete video chats for those who are suspected or confirmed with COVID-19 or currently on 14-day quarantine.

Infection Prevention and Control

• Restrict visitors and non-essential healthcare personnel, except in certain compassionate-care situation.
• Evaluate all persons who enter the facility for signs/symptoms of COVID-19. Temperature checks at entry point. Temperature checks at the start of each shift for all employees.
• The facility will monitor any visitors/vendors/physician for temperature and any signs of respiratory symptoms. The following will also be assessed: history of international travel with 14 days or travel to any of the high-risk states within 14 days, history of exposure to a presumptive or positive COVID-19.
• Visitors with respiratory symptoms will not be permitted to enter the facility at any time.
• Facility will require visitors who are cleared to enter the facility to perform hand hygiene and use of facemask and restrict visitation to resident’s room.
• Signage for visitation, cough etiquette and hand hygiene will be posted in several locations within the facility.
• Visitation restriction will be communicated through mass letter, telephone calls and posting of signage.
• Active screening for residents for fever (Temperature of 100.4) and other COVID-19 symptoms every shift.
• Any supply delivery will be dropped off by the loading dock and/or right by the reception area.
• Alcohol-based hand sanitizers for hand hygiene will be provided in the hallways and on medication carts based on supply availability.
• PPE needed will be made available outside the doors for easy access to the staff.
• Facility will provide EPA disinfectants to allow for frequent cleaning of high touched surfaces and shared resident equipment.
• Suspend communal dining and all group activities.
• Residents are encouraged to remain in their rooms. If the resident leaves their room, they should wear a face covering or face mask; perform hand hygiene, limit movement in the facility and perform social distancing.
• Waste receptable will be provided for PPE
• Implement Standard and Transmission-Based Precaution including use of N95 mask or other respirators.
• Signs posted for direction of PPE to use in residents on Transmission Based Precaution

Resident Management / Cohorting

• Implement cohorting plan that allows for separation of residents, dedicating staff and medical equipment to each of these cohort and allowing necessary space to do so at the onset of an outbreak.
• In the event staffing cannot be designated specifically in the COVID-19 unit, Staff will work from clean unit to COVID Unit., Staff will cluster work load from clean resident to COVID residents.
• Staff will don COVID-19 recommended PPE: N-95 or respirator, eye shield, gloves and gown when entering resident rooms.
• Laboratory confirmed COVID-19 positive residents will be relocated to designated cohort. Private rooms will be provided if feasible. Cohort with another COVID-19 resident maybe done when private room is not possible.
• Person Under investigation will not be moved to COVID-19 cohort until results are confirmed.
• Roommates of COVID-19 residents are considered exposed and should not share a room with other residents unless they have tested negative and has been asymptomatic for 14 days from last exposure.
• Facility will adhere to the CDC guidelines for the discontinuation of Transmission-Based Precaution.
  Symptom-based strategy
  
•   At least 3 days (72 hours) have passed since recovery defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath); and,
•   At least 10 days have passed since symptoms first appeared

Staff Management

• All residents will be provided mask and instructed to cover their nose and mouth when around others, as tolerated.
• Enforce use of universal facemask (source control) for staff while in the facility in addition to active screening of symptomatic staff.
• Staff will be screened by getting their temperature taken and completing a screening tool at the start of their shift
• Any staffs that shows symptoms consistent with COVID-19 will be asked to put on a mask and leave the facility. Such staff would require clearance from IP before returning to work.
• Identify staff who maybe at higher risk for severe COVID-19 and attempt to assign to unaffected units.
• Educate and reinforce sick leave policy including not to report to work when sick.
• Assess staff competency on infection prevention and control measure including putting on and taking off PPE.
• Conserve use of PPE using CDC guidance for PPE contingency strategies.
• Consider staffing contingency for shortage (refer to separate policy).