S T A T E O F N E W Y O R K
I N A S S E M B L Y
November 6, 2020
Introduced by COMMITTEE ON RULES -- (at request of M. of A. Gottfried)
-- read once and referred to the Committee on Health
AN ACT directing the department of health to establish and implement an
infection inspection audit and checklist on residential care facili-
ties, nursing homes and long-term care facilities
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
Section 1. Definitions. For the purposes of this act, the following
terms shall have the following meanings:
(a) "Department" means the department of health.
(b) "Facility" means a licensed nursing home, residential health care
facility, or a facility providing long-term health-related services.
(c) "Nursing home" means a facility providing therein nursing care to
sick, invalid, infirm, disabled or convalescent persons in addition to
lodging and board or health-related service, or any combination of the
foregoing, and in addition thereto, providing nursing care and health-
related service, or either of them, to persons who are not occupants of
(d) "Audit" means the infection control competency audit created by
the department under this act.
(e) "Checklist" means the infection control competency audit checklist
created by the department under this act.
§ 2. Establishing the infection control competency audit. (a) The
department shall promulgate rules and regulations establishing an
infection control competency audit consistent with the provisions of
this act. The audit shall include a competency checklist which incorpo-
rates specific core competencies based on guidance set forth in this
(b) The department shall conduct audits on and after October 1, 2020.
§ 3. Audit evaluation. (a) The infection control competency audit
shall utilize a checklist with a point system to evaluate the competency
of the facility being audited. Each item in the checklist shall be
valued at one point. In order to receive a point for items that have sub
items each sub-item must be met. Facilities subject to the infection
control competency audit shall be required to fulfill the required
criteria of a minimum of eighty percent of the audit checklist.
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
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(b) If a facility meets at least eighty-five percent of the criteria
within the checklist, the facility will be scored as "in adherence" with
the infection control competency audit.
(c) If a facility only meets sixty percent of the required criteria
within the checklist, the facility will be scored as "in adherence but
(d) If a facility meets less than sixty percent of the criteria within
the checklist, the facility will be scored as "not in adherence."
§ 4. Facilities not in adherence with infection control competency
audit. (a) The department shall establish a penalty framework for those
facilities determined to be "not in adherence" with the inspection
control checklist. A facility being found "not in adherence" may result
in revocation or suspension of the facility's license; provided, howev-
er, that no such revocation shall be ordered unless the department has
provided the facility with a fourteen day grace period, solely for a
facility's first time being found "not in adherence", to meet at least
eighty percent of the criteria within the checklist.
(b) Audits shall occur at two-week intervals for facilities that are
found to be "not in adherence" by the established infection control
competency checklist until such facilities meet at least eighty percent
of the criteria within the checklist.
§ 5. Audit standards core competencies. The department shall establish
an infection control competency audit and checklist for facilities which
shall include, but not be limited to:
(a) Infection control. (i) The facility shall have an infection lead
(A) address and improve infection control based on federal and state
public health advisories; and
(B) spend an adequate time in the building focused on activities dedi-
cated to infection control.
(ii) The facility shall have an infection control program with written
policies and procedures which includes, but is not limited to:
(A) A written plan to investigate, control and take action to prevent
infections in the facility;
(B) Written procedures to allow for isolation and universal precau-
tions for residents suspected or confirmed to have a contagious or
infectious disease; and
(C) A record of incidence and corrective actions related to
(iii) During recognized periods of contagious or infectious disease
outbreaks, the facility shall have screening requirements for every
individual entering the facility, including staff, for infectious
(iv) The facility shall establish a dedicated area for those residents
confirmed by testing to be infected with an infectious disease or are
recovering from an infectious disease.
(v) The facility shall have a staffing plan to limit transmission that
shall include, but not be limited to:
(A) Dedicated, consistent staffing teams who directly interact with
residents that are confirmed or suspected to be infected with a conta-
gious or infectious disease; and
(B) Limiting clinical and other staff who have direct resident contact
to specific areas of the facility. There should be no rotation of staff
between various areas of the facility during the period they are working
each day during periods of recognized outbreaks.
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(vi) The facility shall have ensured ongoing access to the necessary
supplies for hand hygiene.
(vii) The facility shall have ensured ongoing access to federally
registered hospital disinfectants or centers for disease control accept-
able alternatives to allow for necessary and appropriate cleaning and
disinfecting of high touch surfaces and shared resident care equipment.
(b) Personal protective equipment. (i) The facility shall possess and
maintain a supply of all necessary items of personal protective equip-
ment in line with the most recent department guidance to protect facili-
ty personnel and residents.
(ii) The facility has a contingency plan to address supply shortages
of personal protective equipment.
(iii) The facility shall train staff and establish protocols for
selecting, donning and doffing appropriate personal protective equipment
and demonstrate competency during resident care.
(iv) The facility shall ensure availability of personal protective
equipment throughout the facility and outside resident rooms when there
are units with separate cohorted spaces for both positive and negative
infectious disease residents.
(v) The facility shall require the use of recommended personal protec-
tive equipment for all front-line staff in line with the most recent
department personal protective equipment guidance.
(c) Staffing. (i) The facility shall demonstrate that there has been
advanced planning, in alignment with the facility's emergency prepared-
ness plans, for backup staffing utilizing all resources in advance of
staff testing to be able to cover shifts based on potential staff quar-
(ii) The facility shall have an employee responsible for conducting a
daily assessment of staffing status and needs during outbreak of infec-
tious or contagious disease.
(d) Clinical care. (i) The facility shall shave infection control
policies that outline the recommended transmission-based precautions
that should be used when caring for residents with respiratory
infection. These policies shall accommodate for department and centers
for disease control guidance on personal protective equipment conserva-
(ii) The facility shall ensure all health care professionals which
enter the facility have been trained to recognize the signs and symptoms
of COVID-19 and other infectious diseases.
(iii) The facility has written requirements for residents to be
screened for symptoms and have their vital signs monitored, including
oxygen saturation and temperature checks at a minimum of two times per
day and documented in the clinical record during a recognized outbreak
of contagious or infectious diseases.
(iv) The facility shall ensure that residents with any suspected
respiratory or infectious illnesses are assessed at a more frequent
(e) Communication. The facility shall have a written plan for daily
communications with staff, residents, and the resident's families
regarding the status and impact of COVID-19 in the facility, including
but not limited to the prevalence of confirmed cases of COVID-19 in
staff and residents and personal protective equipment availability.
(f) Reporting. The facility shall have a written plan for reporting of
increased incidence of infections to the appropriate area office of the
office of health systems management.
§ 6. This act shall take effect immediately.