New York Laws
Article 28 - Hospitals
2803-AA*2 - Nursing Home Infection Control Competency Audit.

(b) A nursing home must meet all metrics on the checklist developed
pursuant to paragraph (a) of this subdivision to be scored as in
compliance with infection control.
(c) If a nursing home fails to meet all metrics on the checklist
developed pursuant to paragraph (a) of this subdivision, the department
shall conduct another infection control audit within ninety days of the
initial determination. The department shall continue to conduct such
ninety day audits until the nursing home is scored as in compliance with
infection control competency. The department may also pursue
administrative penalties, including but not limited to citation for
violation of infection control standards and imposing civil monetary
penalties pursuant to section twelve of this chapter.
3. An audit of core competencies shall include, but not be limited to,
the following, and shall be consistent with focused infection control
survey standards issued by the federal centers for Medicare and Medicaid
services:
(a) Infection control. (i) The nursing home shall assign an infection
lead staff person to implement infection control based on federal and
state public health advisories, guidelines and rules.
(ii) The nursing home shall have a written infection control program
which includes, but is not limited to:
(A) A plan to investigate, control and take action to prevent
infections in the nursing home;
(B) Procedures for isolation and universal precautions for residents
suspected or confirmed to have a contagious or infectious disease; and
(C) A record of incidences and corrective actions related to
infections at the nursing home.
(iii) During an officially declared national emergency, or state or
municipal emergency declared pursuant to article two-B of the executive
law, related to a contagious or infectious disease outbreak, the nursing
home shall have screening requirements for every individual entering the
facility, including staff, for symptoms associated with the infectious
disease outbreak.
(iv) The nursing home shall have a staffing and cohorting plan to
limit transmission, which is based on national (for example, centers of
disease control and centers for Medicare and Medicaid services), state
or local public health authority recommendations. Such staffing and
cohorting plan may include, but not be limited to:
(A) Having dedicated, consistent staffing teams who directly interact
with residents that are confirmed or suspected to be infected with a
contagious or infectious disease;
(B) Limiting clinical and other staff who have direct resident contact
to specific areas of the facility and not rotating staff between various
areas of the facility during the period they are working each day during
periods of recognized outbreaks; and
(C) Having a dedicated space in the facility for cohorting and
managing care for residents with an infectious disease, such as
COVID-19.
(v) The nursing home shall ensure ongoing access to the necessary
supplies for hand hygiene for staff and residents, hospital
disinfectants or alternatives to allow for necessary and appropriate
cleaning and disinfecting of surfaces and shared resident care
equipment.
(vi) The nursing home shall train staff and establish protocols for
selecting, donning and doffing appropriate personal protective equipment
and demonstrate competency during resident care. The nursing home must
keep a record of staff training in proper storage, use, reuse, and
disposal of personal protective equipment.
(vii) The nursing home must designate a staff member or members who is
responsible for ensuring the proper use of personal protective equipment
by all staff.
(b) The nursing home shall demonstrate that there has been advanced
planning, in alignment with the facility's emergency preparedness plans
and pandemic emergency plan, for contingent staffing needs in the case
of staff quarantines that shall have an employee responsible for
conducting a daily assessment of staffing status and needs during an
outbreak of infectious or contagious diseases, and institute a
sick-leave policy that does not punish staff with disciplinary action if
they are absent from work because they are exhibiting symptoms, or test
positive, for an infectious disease. Such policies shall offer the
maximum amount of flexibility to staff and be consistent with state
guidance.
(c) The nursing home shall have a written plan for daily
communications with staff, residents, and the residents' families
regarding the status of infections at the nursing home. Such plan shall
be consistent with the requirements set forth in paragraph (a) of
subdivision twelve of section twenty-eight hundred three of this
article. The nursing home must designate one or more staff members who
are responsible for these communications with staff, residents and
residents' families.
* NB There are 2 § 2803-aa's

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