Timetable for Compliance
Any covered entity to which this Order has been served shall immediately begin implementation and compliance with these requirements, with full implementation and compliance to be achieved no later than ten (10) days after receipt of the Order; provided, however, that if there are changes to the information at: Specifications required under the Commissioner's Order (http://www.health.ny.gov/diseases/communicable/ebola/#commissioner_order), that will be stated on the web site and Covered Entities will be provided additional time per the web site update to achieve full implementation and compliance with such changes.
All general hospitals, diagnostic and treatment centers, off-campus emergency departments, and ambulance services
The Covered Entities referenced above must:
1. Identify to the NYSDOH at least two lead points of contact for EVD preparedness and response activities, one of whom must be available 24 hours per day, seven days per week. The lead points of contact must be assigned to the role of 24/7 Ebola Lead in the Health Commerce System (HCS) Communication Directory by your organization's HCS Coordinator. Instructions are available at: https://apps.health.ny.gov/pub/ctrldocs/alrtview/postings/HCS_Role_Assignment.pdf.
2. Provide all Covered Personnel with personal protective equipment (PPE) that, at a minimum, meets the applicable specifications at Specifications required under the Commissioner's Order (http://www.health.ny.gov/diseases/communicable/ebola/#commissioner_order).
3. Conduct in-person training for all Covered Personnel, on donning and removing PPE, including physically practicing donning and removing PPE in the setting that will be used for Patients. A designated trainer with infection control expertise selected by the Covered Entity must be present at the training to assess whether Covered Personnel have initially achieved satisfactory competence. The training used must, at a minimum, meet the applicable specifications at Specifications required under the Commissioner's Order (http://www.health.ny.gov/diseases/communicable/ebola/#commissioner_order). The Covered Entity must reassess Covered Personnel every month after initially achieving satisfactory competence, and must retrain any Covered Personnel who do not demonstrate satisfactory competence upon reassessment. Only staff who have demonstrated satisfactory competence are allowed to provide care to Patients. The Covered Entity must maintain a log that identifies all Covered Personnel who have received training, the dates they obtained satisfactory competence, and dates and results of monthly reassessments.
4. Maintain a log of all personnel coming into contact with a Patient, or a Patient's area or equipment, regardless of the level of PPE worn at the time of contact. Covered Entities shall measure the temperature twice daily of all personnel who come in contact with a Patient, a Patient's area or equipment, or obtain the temperatures from off-duty personnel. The log must describe each person's measured temperatures and any symptoms. "Contact" for the purposes of this provision is defined as coming in physical contact, entering a patient room, coming within three feet of a Patient, or performing laboratory testing on a specimen from a Patient.
5. Implement a written protocol to safely contain, store and dispose of regulated medical waste in all settings where Patients will be cared for that is in compliance with the applicable specifications at Specifications required under the Commissioner's Order (http://www.health.ny.gov/diseases/communicable/ebola/#commissioner_order).
6. Implement a written protocol to safely clean and disinfect any room, vehicle or equipment with which Patients have come into contact, in accordance with applicable specifications at Specifications required under the Commissioner's Order (http://www.health.ny.gov/diseases/communicable/ebola/#commissioner_order).
All general hospitals, diagnostic and treatment centers, and off campus emergency departments
The Covered Entities referenced above must:
1. Implement a written patient registration protocol for the immediate identification, isolation, and medical evaluation of any person presenting for care with: (1) a travel history within the last 21 days to Liberia, Guinea, or Sierra Leone, or any other country that CDC designates as having a widespread EVD outbreak; and (2) any symptoms of EVD including fever, headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage. The protocol must require reception staff to obtain a travel history and symptoms from all patients upon initial reception. The protocol also must include a plan for the Covered Personnel on all shifts who would be involved in the medical evaluation or other care of a PUI placed in isolation for the medical evaluation of EVD.
2. Conduct training on the patient registration protocol for personnel on all shifts who are involved in patient registration, triage or who work in outpatient settings or emergency departments.
3. Post signs prominently at all entrances, at reception, and at triage locations, in at least English, French, Spanish, Chinese, Russian, Italian, Korean and Haitian Creole asking all persons presenting for care to provide their international travel history.
4. Designate a room for isolation that is in, or in proximity to, the area in which Patients would reasonably be expected to present for care, for patients in need of medical evaluation of EVD. The room must have a door, and it must have access to a private bathroom or have a portable commode. Space must be identified in or adjacent to the room, to be used by staff to don and remove PPE. Such space must have access to hand-washing facilities. If the space is adjacent to the room to be used for isolation, traffic in the area must be restricted to avoid exposure of other persons. Access to the room to be used for isolation and adjacent rooms must be restricted to avoid exposure of other persons.
5. Maintain a list of all persons who came into contact with a Patient before they were placed in isolation, including direct physical contact or coming within three feet of a Patient. The list shall be provided to the local health department where the hospital is located. The Covered Entity shall monitor the temperature and symptoms of any of its personnel on this list.
6. Immediately notify the local health department or the New York City Department of Health and Mental Hygiene (NYCDOHMH), as applicable, when a PUI is placed in isolation for the medical evaluation of EVD.
7. Conduct drills with personnel on all shifts on the patient registration protocol initially within 5 days of receipt of the Order and then every month, following the initial drill. A written description of the drill, including the items reviewed, number of staff included in the drill, gaps identified, conclusions, and next steps, must be maintained and made available to the New York State Department of Health upon request.
End Excerpt: Attachment continues with more information for All general hospitals
Please read the ENTIRE Order for Summary Action (link).
