Outbreak Consideration for Long Term Care Communities COVID-19 After Action Report

AHCA/NCAL has developed an AAR / Improvement Plan template that can be used to appropriately document a facility’s response to the COVID- 19 PHE. Without proper documentation, surveyors may not give a facility credit for the community-wide, full-scale exercise equivalency. It is critical for facility’s to complete the template and not simply present the document to surveyors without customization.

View Template

Setting up an Incident Command Structure: Implementing the Nursing Home Incident Command System

The  initial step in managing a pandemic infection is to establish an incident command structure. Here is a video that describes how that structure can be established, the tools and forms necessary to assure compliance with mandatory emergency preparedness elements, and other resources about NHICS.

Nursing Home Incident Command System (NHICS) | Resources

Tabletop Exercises and Training Resources

Infection Control Tabletop Exercise Scenario

Understanding the Role of the Infection Preventionist

During a pandemic, the role of the Infection Preventionist is essential in assisting the facility in managing all elements of the pandemic. According to current regulations, each facility is required to designate one or more individuals as the infection Preventionist(s) (IP)(s) who are responsible for the facility’s Infection Control Program. (CMS §483.80(b) F882). According to this regulation, the IP must:

  • 483.80(b)(1) Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field;
  • 483.80(b)(2) Be  qualified by education, training, experience or certification;
  • 483.80(b)(3) Work at least part-time at the facility; and
  • 483.80(b)(4) Have completed specialized training in infection prevention and control.
  • 483.80 (c) IP participation on quality assessment and assurance committee.

The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility’s quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.

The AZ Disaster Ready Infection Control (EPIC) program has developed resources to assist facility IPs in managing this important role.

  • Monthly IP coaching/networking calls are held with support from the EPIC clinical team. View the recorded calls:
  • DR EPIC IP – Role and Task Checklist – This is a description of tasks and terms, along with a checklist of necessary tasks for IPs to complete on a weekly, monthly, quarterly, and annual basis can be found

Establishing a Baseline of Compliance

Understanding where your gaps and opportunities are is an important step in assuring your facility is ready to handle an emergency situation such as a pandemic. There are a number of assessments and audit tools that can be important to use in determining your readiness.

Here are some important tools:

Understanding Industrial Hygiene

Assuring that your facility is free from environmental hazards is an essential component of pandemic influenza preparedness.

Other Additional Industrial Hygiene Resources

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  • IICRC S500 Standard and Reference Guide for Professional Water Damage Restoration.


Ensuring Administrative Oversight and Program Management