Pandemic Emergency Plan (PEP)

Section 6 Infectious Disease/Pandemic Emergency

The circumstances of infectious disease emergencies, including ones that rise to the level of a pandemic, vary due to multiple factors, including type of biological agent, scale of exposure, mode of transmission and intentionality. Infectious disease emergencies can include outbreaks, epidemics and pandemics. Kendal on Hudson’s Pandemic Emergency Plan (PEP) outlines the strategies for responding to all types of infectious diseases, including those that rise to the higher level of pandemic.

The KOH PEP addresses protection of staff, residents and families against infection. The plan is operationalized through policies and procedures which detail how to

  • train clinical staff in understanding the mode of transmission and mitigating strategies for the pathogen
  • inform residents, families and non-clinical staff on the early symptoms of disease
  • train all staff, residents, and visitors on the importance of standard infection control precautions (e.g., handwashing, respiratory hygiene/cough etiquette, etc.)
  • ensure vaccination of residents and staff if vaccines are available
  • have laboratory testing when indicated
  • ensure surveillance and early detection of infection in the facility among resident & staff
  • ensure treatment of infected individuals, according to current clinical practice guidelines
  • ensure strict adherence to appropriate transmission-based precautions
  • restrict visitors as necessary
  • ensure display of signage at the entrance to the facility restricting entry by any persons who have been exposed to or have symptoms of the infectious disease threat
  • ensure screening of visitors at facility entry points for symptoms of the infectious disease; and screening employees for symptoms before coming on duty (including denying entry to any visitor or staff who do not meet screening criteria)
  • maintain social distancing
  • ensure proper communications have been established with all Federal/State/and Local Health Agencies in order to report and track all outbreaks and reported cases
  • ensure that proper communication has been established between Kendal on Hudson and residents/families

The PEP addresses Westchester County Health Department prevention priorities as well as Kendal on Hudson’s specific risks for each pandemic event. The PEP also responds to subsection 12 of Section 2803, Chapter 114 of the Laws of 2020, for infectious disease events that rise to the level of a pandemic.

Key components of the PEP are as follows:

  • a Communication Plan,
  • protection plans against infection for staff, residents, and families, including the maintenance of a 2-month (60 day) supply of infection control personal protective equipment and supplies and
  • a plan for preserving a resident’s place in and/or being readmitted to a residential health care facility or alternate care site if such resident is hospitalized, in accordance with all applicable laws and regulations.

The Skilled Nursing Facility has an Infection Control Committee which meets quarterly, however, in times of infectious disease events that rise to the level of a pandemic a Kendal on Hudson – wide Infection Control Team will commence to mount an appropriate response to the crisis at hand. The members of the Infection Control Team will include the Operations Team and key Clinical Leadership staff. Collectively, the IC Team will be responsible to ensure that the components of this PEP are in place and are carried out. To successfully enact and operationalize this PEP, the IC Team will meet regularly and will drive the communication provided to all stakeholders.

Kendal on Hudson Infection Control Program (ICP)

Kendal on Hudson has an Infection Control Prevention Program (ICP) which is established and maintained to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of communicable disease and infections.

The Program ensures routine and on-going infectious disease surveillance that is adequate to identify background rates of infectious diseases and detect significant increases above those rates. This will allow for immediate identification when rates increase above these usual baseline levels.

Kendal on Hudson has a program for surveillance and detection of infectious diseases among residents and staff and actively monitors public health surveillance and advisories. The program will be augmented to address each specific pandemic event as warranted. The identification of infection rates in residents as well as any increase from their baseline of infections is immediately tracked and reported to the Director of Nursing, Medical Director, and other appropriate staff for review by the Infection Control Preventionist. The tracking of all residents and staff with symptoms of an infectious disease is evaluated and tested when appropriate for presence of the disease and following current CDC and State guidelines.

Resources to support adequate response include contracts with laboratory services for testing of employees as well as residents. A testing plan which will outline testing frequency and location of site(s) for each constituent requiring testing for compliance.

Applicable Policies & Procedures:

  • Infection Prevention and Control Program
  • Infectious Disease Threat, Surveillance and Detection
  • Outbreak of Communicable Disease
  • Surveillance for Infections
  • Staff Testing Plan (specific to each pandemic issue)
  • Testing of Residents
  • Exposure Classification of Tasks/Procedures
  • Reporting of Suspected or Confirmed Communicable Disease Cases

Staff Education

Kendal on Hudson ensures staff educational in-servicing annually, and as necessary on both routine and pandemic infection control diseases and control practices. Included in the educational curriculum are the elements of the reporting requirements, exposure classification risks, prevalence of symptom identification, and the correct usage of personal protective equipment (PPE) per federal and state guidance requirements.

Applicable Policies & Procedures:

  • Exposure Classification of Tasks/Procedures
  • Reporting of Suspected or Confirmed Communicable Disease Cases
  • Personal protective Equipment Donning On and Off Properly
  • Proper Usage of Personal Protective Equipment

Cohorting and Isolation of the Infection

Kendal on Hudson ensures that residents are isolated/cohorted and or transferred based on their infection status in accordance with applicable NYSDOH and Centers for Disease Control and Prevention (CDC) guidance.

Kendal on Hudson has taken precautionary measures to ensure that any resident that is diagnosed with a communicable disease or presumed to be infectious due to presence of symptomology will be clinically managed, as able, within the Health Center or will be transferred to an acute care setting with a physician’s order. Kendal on Hudson’s Skilled Nursing Facility (SNF/Clearwater) has only private rooms. To cohort infected residents, a hallway of the SNF may be designated and a series of negative pressure private rooms able to accommodate full isolation precautions may be created.

To isolate infection, separate or designated staffing patterns will be developed to provide care for each resident cohort (i.e. infectious versus non-infectious).

During a pandemic event, measures commensurate with the specific infectious disease will established to ensure that all stakeholders (i.e. residents of all levels of care, staff, visitors, contractors and vendors) engage in social distancing to the degree possible to their individual role(s). Consideration includes “essential” versus “non-essential” in relation to service provision and activities. A systematic and scaled approach will be taken to reduce (or eliminate) activities and implement changes in service provision and physical space arrangements. Examples include but are not limited to reduction (or discontinuation) of congregate activities, congregate dining and transition to electronic platforms to support group meetings, where able.

Applicable Policies & Procedures:

  • Isolation Precautions and Cohorting of Residents
  • Transferring Resident with a Suspected or Confirmed Communicable Disease
  • Staffing for Skilled Nursing During an Outbreak
  • Surge Staffing
  • Communal Dining
  • Quarantine of Residents / Activities

Administrative Controls

Commensurate with the infectious disease event, Kendal on Hudson establishes administrative controls and procedures to address staff wellness/symptom monitoring, visitor policies and employee testing and absence plans. Specifically, KOH protects the health and well-being of residents and staff members by allowing staff members to be absent from their regularly scheduled shifts to care for themselves or their immediate family members living in the same household who become ill with or are quarantined due to exposure to the pandemic illness while maintaining their regular pay for a set maximum period of time.

Kendal on Hudson will obtain and maintain current guidance, signage, advisories from the NYSDOH, CMS and Centers for Disease Control and Prevention (CDC) on disease- specific response actions. Directives and advisories will be obtained via the Health Commerce System and Kendal on Hudson will additionally rely partners such as LeadingAge New York, Friends Services Alliance (FSA) and Kendal Corporation as sources of information and advisement.

Kendal on Hudson will adhere strictly to our response actions including management of residents and staff suspected or confirmed to have the disease by following our specific policies and procedures. Line lists of residents and staff suspected or confirmed to be infected with the pandemic disease will be maintained and will be made available to any required oversight authority.

Subject to any superseding New York State Executive Orders and/or NYSDOH guidance that may otherwise temporarily prohibit visitors, the facility will advise visitors to limit visits to reduce exposure risk to residents and staff.

If necessary, and in accordance with applicable New York State Executive Orders and/or NYSDOH guidance, the facility will implement the following 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.

For Clearwater, the Skilled Nursing Facility, in accordance with all applicable laws and regulations, including but not limited to 10 NYCRR 415.3(i)(3)(iii), 415.19, and 415.26(i); and 42 CFR 483.15(e), Kendal on Hudson will assure that residents requiring transfer to acute care settings will have their space preserved within Clearwater to facilitate readmission. While the space will be reserved, readmission at the time of discharge from the acute setting will be dependent upon the ability of Clearwater to provide the proper level of care and services necessary. Should the resident’s scope of need exceed what Clearwater is able to provide, Clearwater staff will work with the resident/family to facilitate discharge to the appropriate facility setting.

Applicable Policies & Procedures:

  • Pandemic Sick Policy
  • Health Screening of Staff & Visitors During Pandemic Outbreak
  • Visitation During Covid-19 Outbreak / Compassionate Care Visits
  • Limited Skilled Nursing Visitation
  • Transferring resident with a Suspected or confirmed Communicable Disease
  • Hospital Transfers and Re-admissions

Mandatory Reporting

Kendal on Hudson participates in all required reporting systems to meet State and Federal regulations for pandemic monitoring and tracking. To ensure consistent and accurate reporting, adequate facility staff have access to communicable disease reporting tools and other outbreak specific reporting requirements on the Health Commerce System and the National Healthcare Safety Network (NHSN).

The facility reports suspected or confirmed communicable diseases as mandated under the New York State Sanitary Code (10 NYCRR 2.10 Part 2), as well as by 10 NYCRR 415.19.

Applicable Policies and Procedures:

  • Health Commerce System (HCS)
  • Reporting of Suspected or Confirmed Communicable Disease Case


Kendal on Hudson will provide and maintain clear and concise communications with residents and their families loved ones and guardians during a pandemic situation. Routine communication will be maintained with residents and resident representatives via letter and/or email regarding the facility’s efforts to prevent and mitigate the spread of infectious disease.

All staff, vendors and other relevant stakeholders to share pertinent procedures related to minimizing exposure risks to residents and to provide information regarding changes in facility protocols that will impact the individual stakeholder’s typical routine at the community. It will be ethe responsibility of each Kendal on Hudson manager to work with their respective stakeholder to ensure compliance.

The Kendal on Hudson website will be periodically updated with up-to-date information regarding the entire community’s experience with and infection control efforts surrounding the current pandemic. Communication will include

  • detail on how, when and which activities/procedures/restrictions will be eliminated and enforced. Similarly, as reopening occurs and activities are resumed, operational changes will be communicated with staff, families/guardians, and other relevant stakeholders
  • education about the disease and the facility’s response strategy at a level appropriate to their interests and need for information

For Clearwater, the Skilled Nursing Facility, in accordance with subsection 12 of Section 2803, Chapter 114 of the Laws of 2020, when an infectious disease event rises to the level of a pandemic:

  • Family members/guardians/designated representatives of infected residents will be updated once per day and upon a change in the resident’s condition.
  • Electronic updates will be provided, at minimum once per week, to all residents and authorized family members including the number of infections and deaths experienced at the facility. Note: individuals who cannot receive electronic updates may elect an alternate method of receipt by contacting Administration.

Kendal on Hudson will support multiple platforms to ensure that Health Center residents are able to communicate and have on-going contact with family members and friends and continue to have access to individuals outside of the Kendal on Hudson community as it is essential to the health and well-being of all residents. Platforms to facilitate this include utilizing Facetime, Skype or any other electronic platform, phone calls or window visits. Daily access to video-based communication will be available at no cost to Clearwater, Adirondack, and Sunnyside residents.

Applicable Policies & Procedures

  • Communication During Pandemic

Environmental Controls

Kendal on Hudson’s routine operations require a policy and procedure for the safe handling and disposal of contaminated/bio-medical waste on a regular basis. In the event of a pandemic, existing policies will be evaluated for adequacy with adjustments made as required. Each area producing contaminated waste will have an identified location for the collection of such waste. Staff will be trained in proper handling should it deviate from normal.

Heightened scrutiny of common area cleaning and more frequent cleaning of high-touch, high-traffic areas will be instituted to the degree necessary to respond to each specific pandemic event. Cleaning and decontamination in response to the infectious disease in accordance with any applicable NYSDOH, EPA and CDC guidance, as well as with facility policy for cleaning and disinfecting of isolation rooms.

Applicable Policies & Procedures:

  • Pandemic Cleaning Supply Inventory
  • Contaminated Waste Disposal

Personal Protective Equipment and Critical Supplies

Section 8 of Kendal on Hudson’s Emergency Preparedness Plan provides detail regarding contracted vendors for critical supplies and Personal Protective Equipment (PPE). Critical supplies include, but care not limited to, food, water, medications, personal care items, medical supplies, and cleaning agents.

Personal Protective Equipment

It is the policy of Kendal on Hudson to possess and maintain a 60-day supply of all necessary items of Personal Protective Equipment (PPE) required to respond to a pandemic emergency.

PPE includes but is not limited to:

  • N95 and/or KN95 respirators
  • Surgical Masks
  • Face Shields and/or eye protection
  • Gowns
  • Sanitizer and disinfectants, ample to respond to the specific infectious disease

Kendal on Hudson will ensure that proper contracts and vendor relationships are in place to source and procure PPE. Further, Kendal on Hudson will leverage resources available through Kendal Corporation. Critical vendors are listed in the KOH Emergency Preparedness Plan, Section 8.9 through 8.31.

At the time of an infectious outbreak, the facility’s need for each category of PPE will be evaluated. Aggregate community needs for PPE will be considered as well as individual needs of each regulated health care entity. This will be done under the direction of the Infection Control Preventionist / Designee. Analysis will include an in depth look at each department within the community, every job role within each department, and will identify the specific PPE necessary based on each worker’s level of risk/exposure in daily activity. The analysis will result in identification of a facility “burn rate”. Outcomes of the analysis, and “burn rate”, will be utilized by the department leading procurement and inventory processes to ensure adequate stock on hand.

Note: Kendal on Hudson will comply with any NYS Executive Orders or NYSDOH regulations governing PPE supply requirements executed during a specific disease outbreak or pandemic.


Kendal on Hudson has a contract with the vendor pharmacy for medications as well as a back-up supply of medications in the on-site Omnicell medication machine that houses approximately 61 medications from the most used medications and narcotics available per MD orders is used when necessary as back-up to our current supply. The stock medications come from the pharmacy which we always have a 60-day supply in house for administration and back-up continually ordering based on our expiration dates. Vaccine procurement for the flu season are secured via pre-order in the Spring every year for the up-coming inoculation of Residents and staff members in the Fall of the same year. The infusion Therapy cart has an adequate supply of fluids and allowed medications, as well as supplies for Infusion Therapy should we need to provide this clinical service.

Cleaning Agents

The Environmental Services Department will ensure that cleaning agents necessary to ensure proper cleaning of all spaces are available to address the current infectious disease event. At the outset of an internal or external outbreak, the EVS Manager will procure and consistently maintain a 60-day supply.

Applicable Policies and Procedures:

  • Personal Protective Equipment (PPE) Supply
  • Stock Medication Supply
  • Pandemic Cleaning Supply Inventory
  • Exposure Classification of Tasks/Procedures
  • Infusion Therapy Supply Cart
  • Immunization Policy

Post-Pandemic / Recovery

The Kendal on Hudson IC Team will meet regularly throughout the pandemic as noted in the opening of this PEP. As the immediate threat of the current situation wanes, evaluation will take place to assess KOH’s risk level and to identify steps to reopen and resume previous level of services (if possible) in a thoughtful and careful way. Plans to recover/return to normal will be done in accordance with State and CDC guidance at the time of each specific infectious disease or pandemic event e.g., regarding how, when, which activities /procedures /restrictions may be eliminated, restored and the timing of when those changes may be executed.