Emergency Preparedness and Planning Toolkit for Long-Term Care Providers

Transcription

1 SANTA CLARA COUNTY EMERGENCY MEDICAL SERVICES AGENCY Allied Healthcare Facilities Work Group Emergency Preparedness and Planning Toolkit for Long-Term Care Providers 976 Lenzen Avenue Suite 1200 San Jose, CA Phone: Fax:

2 Disclaimer: The information contained in this toolkit binder is intended to serve as a guide and resource for the enhancement and/or development of a comprehensive emergency operations plan based on current guidelines, planning considerations and recommended best practices. Providers may use or adapt from any of the information provided in this binder.

3 TABLE OF CONTENTS Santa Clara County Letter and Disclaimer Santa Clara County Emergency Contacts Personal Preparedness Emergency Checklist for Family, Residents, Caregivers, and Guardians Emergency Planning Checklist for Effective Health Care Facility Planning General Emergency Supplies Checklist Food Supplies Checklist Hazard and Vulnerability Analysis Tools Disaster Planning Guide for Home Health Care Providers Disaster Preparedness Plan Template for Long-Term Care Facilities Writing Guide for a Memorandum of Understanding (MOU) Transportation and Emergency Preparedness Checklist Long-Term Care Facility Evacuation Planning Considerations Ombudsman Long-Term Care Facility Resident Evacuation Assessment Checklist National Criteria for Evacuation Plan Template Long-Term Care and Other Residential Facilities Pandemic Influenza Planning and Supply Checklists Pandemic Influenza Workbook for Long-Term Care Providers General Emergency Supplies Checklist Regulatory Standards and Requirements Crosswalk Emergency Preparedness Courses and Training List Santa Clara County City Phone Numbers and City Website List Tab A Tab B Tab C Tab D Tab E Tab F Tab G Tab H Tab I Tab J Tab K Tab L Tab M Tab N Tab O Tab P Tab Q Tab R

4 Cell Phone Emergency Number to Campbell Cupertino Gilroy Los Altos Los Altos Hills Los Gatos Websites & Information Services Emergency Digital Information System: Notifications to your National Oceanic & Atmospheric Admin: Real time hazards information Milpitas Police Fire Pacific Gas & Electric: Monte Sereno Morgan Hill Mt. View Palo Alto San Jose San Martin Santa Clara Police Fire Saratoga Sunnyvale Unincorporated Santa Clara Valley Water District: Real time hazards information United States Geological Survey: Real time hazards information Volunteer Center of Silicon Valley: Disaster Staffing : Information & Referral Countywide KCBS 740 AM & FM, KGO 810 AM, KSJO 92.3 FM, KLIV 1590 AM City Specific Cupertino 1670 AM Gilroy 1610 AM Saratoga 1610 AM Sunnyvale 530 AM Milpitas 1620 AM Morgan Hill 1610 AM SANTA CLARA COUNTY 12/06/08

5 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Survey & Certification Emergency Preparedness for Every Emergency EMERGENCY PLANNING CHECKLIST RECOMMENDED TOOL FOR PERSONS IN LONG-TERM CARE FACILITIES & THEIR FAMILY MEMBERS, FRIENDS, PERSONAL CAREGIVERS, GUARDIANS & LONG-TERM CARE OMBUDSMEN Part I: For Long-Term Care Residents, Their Family Members, Friends, Personal Caregivers, & Guardians Target Date Date Completed Emergency Plan: Prior to any emergency, ask about and become familiar with the facility s emergency plan, including: Location of emergency exits How alarm system works and modifications for individuals who are hearing and/or visually impaired Plans for evacuation, including: How residents/visitors requiring assistance will be evacuated, if necessary How the facility will ensure each resident can be identified during evacuation (e.g., attach identification information to each resident prior to evacuation) Facility s evacuation strategy Where they will go How their medical charts will be transferred How families will be notified of evacuation Will families be able to bring their loved one home rather than evacuating, which is often less traumatic than a move to a new facility? How family members can keep the facility apprised of their location and contact information (e.g., address, phone number, address), so the facility will be able to contact them, and family members will be able to check with the facility to meet their loved one following an emergency How residents and the medicines and supplies they require will be prepared for the emergency, have their possessions protected and be kept informed during and following the emergency How residents (if able) and family members can be helpful (for example, should family members come to the facility to assist?) How residents, who are able, may be involved during the emergency, including their roles and responsibilities. Note: It is important for staff to know each resident personally, and whether involving him/her in the emergency plan will increase a sense of security or cause anxiety.. For example, residents may have prior work or personal experience that could be of value (health care, emergency services, military, amateur ham radio operators, etc.) Provide the opportunity for residents to discuss any fears and what actions may help to relieve their anxiety (e.g., a flashlight on the bed, water beside the bed, etc.). Note: Some of the recommended tasks may exceed the long-term care facility s Federal regulatory requirements. Page 1 September 2007

6 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Survey & Certification Emergency Preparedness for Every Emergency Part II: Targeted Date Date Completed Helping Residents in a Relocation: Suggested principles of care for relocated residents include: Encourage the resident to talk about expectations, anger, and/or disappointment Work to develop a level of trust Present an optimistic, favorable attitude about the relocation Anticipate that anxiety will occur Do not argue with the resident Do not give orders Do not take the resident s behavior personally Use praise liberally Be courteous and kind Include the resident in assessing problems Encourage family participation Ensure staff in the receiving facility introduce themselves to residents For Long-Term Care Ombudsmen State Ombudsman Responsibilities: Become generally familiar with state emergency plans pertinent to long-term care facilities, including the state or federal agency that may be established to serve as a clearinghouse for facility evacuations: know the name, telephone number and of the person to whom long-term care facility evacuations and evacuees names should be reported. If no clearinghouse has been established, advocate for one. At least annually, ensure that all regional ombudsman coordinators and local ombudsmen and/or representatives read, are familiar with and have the opportunity to discuss resources, such as the two recommended CMS emergency preparedness checklists pertaining to long-term care facilities: the CMS Emergency Preparedness Checklist Recommended Tool for Effective Health Care Facility Planning and this CMS Emergency Planning Checklist Recommended Tool for Persons Living In Long-Term Care Facilities, Their Family Members, Friends, Personal Caregivers, Guardians, & Long-Term Care Ombudsmen. Maintain at home and office hard copies of current regional ombudsman contact information, including cell phones. Prior to an anticipated disaster, if the state ombudsman program has regional coordinators and/or other program representatives in the areas likely to be affected, call them to make sure they have assigned representatives to carry out the responsibilities listed in the section below pertaining to local ombudsman programs. Immediately following a disaster, contact regional ombudsman coordinators/representatives in the affected areas to provide support and Note: Some of the recommended tasks may exceed the long-term care facility s Federal regulatory requirements. Page 2 September 2007

7 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Survey & Certification Emergency Preparedness for Every Emergency resources, as needed and feasible. Regional Ombudsman Coordinator & Representative Responsibilities (for states with regional/local ombudsman programs and/or representatives) Prior to any emergency, ombudsmen: Become generally familiar with the local emergency plans and the roles of local, county and state agencies in a disaster, especially as pertaining to long-term care facilities. Read and become familiar with emergency plans of facilities in the region for which the regional program has responsibility. If a state or regional clearing house for evacuations has been established, know the agency, phone number and where facility evacuations will be reported. Maintain, at home and office, hard copies of current contact information for facilities, other ombudsmen and appropriate agencies, especially the local emergency management agency. Prior to an anticipated emergency and following an emergency: The regional ombudsman program coordinator assigns a representative to check on each facility covered by the program and reviews the responsibilities listed below with representatives assigned to facilities. Assigned representatives check on assigned facilities to assure that residents rights are protected prior to, during and after evacuation and provide information about conditions and any evacuation to the regional ombudsman coordinator; regional coordinator provides information to the state ombudsman office. Exception: when the ombudsman lives in an area under mandatory evacuation; however, if possible, the ombudsman should contact the facility by telephone, even if the area is under evacuation order. (Some states may have other specific procedures in place which ombudsman representatives would be required to follow.) Ombudsman representatives visit residents as soon as possible after the disaster, whether they have been sheltered in the facility or transferred to another location. (If they have been transferred out of the region, state ombudsman and regional coordinators coordinate visitation by ombudsman representatives in the receiving region.) Discuss and record their immediate status/needs. If the state and local ombudsman coordinator decide a form is needed, use appropriate form to record information (a sample form is attached) and send a copy of the form to whomever they specify. Take urgent action to help obtain the resources and assistance residents need to be safe and, if they have been evacuated, find their loved ones and relocate to an area/facility or other setting of their preference. (Note: the ombudsman is not responsible for providing resources but instead should be aware of available resources and work to ensure they are provided to residents.) Track, if possible, the impact of the disaster on the residents Determine whether the facility has reported the names and destination of any evacuated residents to the clearinghouse (if state or region has Note: Some of the recommended tasks may exceed the long-term care facility s Federal regulatory requirements. Page 3 September 2007

8 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Survey & Certification Emergency Preparedness for Every Emergency established a clearinghouse), and is prepared to handle transfer trauma and support facility staff in handling resident trauma. As provided in Part I, above, suggested principles of care for the relocated residents include: Encourage the resident to talk about expectations, anger, and/or disappointment Work to develop a level of trust Present an optimistic, favorable attitude about the relocation Anticipate that anxiety will occur Do not argue with the resident Do not give orders Do not take the resident s behavior personally Use praise liberally Be courteous and kind Include the resident in assessing problems Encourage staff in the receiving facility to introduce themselves to residents Encourage family participation Counsel residents about their rights to: Be informed regarding the status of the relocation Be provided information on alternative living arrangements and the options available Be assessed for eligibility for funding and supports to safely return to live in their home or community Visit other facilities to help them better decide where to live Seek representation by an ombudsman or other representative/advocate available in the area Expect to receive adequate care and treatment services during the relocation Meet with the facility staff to express any concerns Seek a review of any relocation changes with which they disagree Expect that their rights, while a resident of any facility, will not be violated (Note: Adapted from WI Ombudsman Program brochure for residents of facilities scheduled for closure) Note: Some of the recommended tasks may exceed the long-term care facility s Federal regulatory requirements. Page 4 September 2007

9 Ombudsman Name: Region: OMBUDSMAN LONG-TERM CARE FACILITY RESIDENT EVACUATION ASSESSMENT CHECKLIST Resident Evacuee Information (see reverse) Previous Facility: Additional ombudsman follow-up is necessary City: County: Assessment Date Current Facility: Yes No N/A City: County: Does the facility have power? If not, do the residents have a source of light (e.g., lamps on a generator or handheld flashlights)? Comment: Did the facility suffer any significant structural damage? Is so please indicate. Comment: Are high traffic areas, such as hallways, common areas, and doorways, clear of debris so residents may move freely throughout the facility? Comment: Did the facility receive evacuees from other facilities? If so, how long are the displaced residents scheduled stay at the new facility? Comment: Have residents and their representatives been consulted regarding their wishes for return or transfer to a different facility? Comment: Have plans been made to return or transfer residents elsewhere, according to the wishes of the displaced residents and their representatives? Comment: According to displaced residents, do they have their personal belongings (e.g., clothing, toiletries, mementos, etc.)? Comment: According to the displaced residents, is the facility geographically accessible to their family and friends? If not, what arrangements can be made to accommodate them? Comment: Is there an adequate source of food, ice, and water available to meet basic needs? If not, does the facility need these items to be delivered? Comment: Are vital medications available and administered per residents medical condition? If the medication is not available, are the residents conditions being monitored and documented? Comment: According to the residents, are there sufficient staff to provide adequate care and services to meet their needs? Comment: Is there anything additional the Long-Term Care Ombudsman Program can do to assist in other areas besides those outlined here? Comment: Ask facility for a list of evacuees and their originating or destined facilities. Please forward this information to the district coordinator for additional follow-up. Staff interviewed: See reverse for additional information: Position: Note: This form has been adapted from the Florida Ombudsman Program September 2007

10 Resident Evacuee Information Any Resident(s) Concerns Number of residents evacuated: Number of residents transferred to this facility: In the space provided below, please indicate the names of residents who have been transferred/evacuated Residents Names Residents Names Evacuee or Transferred Residents Concerns Additional Information Note: This form has been adapted from the Florida Ombudsman Program September 2007

11 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Survey & Certification Emergency Preparedness for Every Emergency EMERGENCY PREPAREDNESS CHECKLIST RECOMMENDED TOOL FOR EFFECTIVE HEALTH CARE FACILITY PLANNING Not Started In Progress Completed Tasks Develop Emergency Plan: Gather all available relevant information when developing the emergency plan. This information includes, but is not limited to: Copies of any state and local emergency planning regulations or requirements Facility personnel names and contact information Contact information of local and state emergency managers A facility organization chart Building construction and Life Safety systems information Specific information about the characteristics and needs of the individuals for whom care is provided All Hazards Continuity of Operations (COOP) Plan: Develop a continuity of operations business plan using an all-hazards approach (e.g., hurricanes, floods, tornadoes, fire, bioterrorism, pandemic, etc.) that could potentially affect the facility directly and indirectly within the particular area of location. Indirect hazards could affect the community but not the facility and as a result interrupt necessary utilities, supplies or staffing. Determine all essential functions and critical personnel. Collaborate with Local Emergency Management Agency: Collaborate with local emergency management agencies to ensure the development of an effective emergency plan. Analyze Each Hazard: Analyze the specific vulnerabilities of the facility and determine the following actions for each identified hazard: Specific actions to be taken for the hazard Identified key staff responsible for executing plan Staffing requirements and defined staff responsibilities Identification and maintenance of sufficient supplies and equipment to sustain operations and deliver care and services for 7-10 days Communication procedures to receive emergency warning/alerts, and for communication with staff, families, individuals receiving care, before, during and after the emergency Designate critical staff, providing for other staff and volunteer coverage and meeting staff needs, including transportation and sheltering critical staff members family Collaborate with Suppliers/Providers: Collaborate with suppliers and/or providers who have been identified as part of a community emergency plan or agreement with the health care facility, to receive and care for individuals. A surge capability assessment should be included in the development of the emergency plan. Similarly, evidence of a surge capacity assessment should be included if the supplier or provider, as part of its emergency planning, anticipates the need to make housing and sustenance provisions for the staff and or the family of staff. Decision Criteria for Executing Plan: Include factors to consider when deciding to evacuate or shelter in place. Determine who at the facility level will be in authority to make the decision to execute the plan to evacuate or shelter in place (even if no outside evacuation order is given) and what will be the chain of command. Note: Some of the recommended tasks may exceed the facility s minimum Federal regulatory requirements * Task may not be applicable to agencies that provide services to clients in their own homes Page 1 September 2007

12 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Survey & Certification Emergency Preparedness for Every Emergency EMERGENCY PREPAREDNESS CHECKLIST RECOMMENDED TOOL FOR EFFECTIVE HEALTH CARE FACILITY PLANNING Not Started In Progress Completed Tasks Communication Infrastructure Contingency: Establish contingencies for the facility communication infrastructure in the event of telephone failures (e.g., walkie-talkies, ham radios, text messaging systems, etc.). Develop Shelter-in-Place Plan: Due to the risks in transporting vulnerable patients and residents, evacuation should only be undertaken if sheltering-inplace results in greater risk. Develop an effective plan for sheltering-in-place, by ensuring provisions for the following are specified: * Procedures to assess whether the facility is strong enough to withstand strong winds, flooding, etc. Measures to secure the building against damage (plywood for windows, sandbags and plastic for flooding, safest areas of the facility identified. Procedures for collaborating with local emergency management agency, fire, police and EMS agencies regarding the decision to shelter-in-place. Sufficient resources are in supply for sheltering-in-place for at least 7 days, including: Ensuring emergency power, including back-up generators and accounts for maintaining a supply of fuel An adequate supply of potable water (recommended amounts vary by population and location) A description of the amounts and types of food in supply Maintaining extra pharmacy stocks of common medications Maintaining extra medical supplies and equipment (e.g., oxygen, linens, vital equipment) Identifying and assigning staff who are responsible for each task Description of hosting procedures, with details ensuring 24-hour operations for minimum of 7 days Contract established with multiple vendors for supplies and transportation Develop a plan for addressing emergency financial needs and providing security Develop Evacuation Plan: Develop an effective plan for evacuation, by ensuring provisions for the following are specified: * Identification of person responsible for implementing the facility evacuation plan (even if no outside evacuation order is given) Multiple pre-determined evacuation locations (contract or agreement) with a like facility have been established, with suitable space, utilities, security and sanitary facilities for individuals receiving care, staff and others using the location, with at least one facility being 50 miles away. A back-up may be necessary if the first one is unable to accept evacuees. Evacuation routes and alternative routes have been identified, and the proper authorities have been notified Maps are available and specified travel time has been established Adequate food supply and logistical support for transporting food is described. The amounts of water to be transported and logistical support is described. The logistics to transport medications is described, including ensuring their protection under the control of a registered nurse. Procedures for protecting and transporting resident/patient medical records. The list of items to accompany residents/patients is described. Note: Some of the recommended tasks may exceed the facility s minimum Federal regulatory requirements * Task may not be applicable to agencies that provide services to clients in their own homes Page 2 September 2007

13 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Survey & Certification Emergency Preparedness for Every Emergency EMERGENCY PREPAREDNESS CHECKLIST RECOMMENDED TOOL FOR EFFECTIVE HEALTH CARE FACILITY PLANNING Not Started In Progress Completed Tasks Identify how persons receiving care, their families, staff and others will be notified of the evacuation and communication methods that will be used during and after the evacuation Identify staff responsibilities and how individuals will be cared for during evacuation, and the back-up plan if there isn t sufficient staff. Procedures are described to ensure residents/patients dependent on wheelchairs and/or other assistive devices are transported so their equipment will be protected and their personal needs met during transit (e.g., incontinent supplies for long periods, transfer boards and other assistive devices). A description of how other critical supplies and equipment will be transported is included. Determine a method to account for all individuals during and after the evacuation Procedures are described to ensure staff accompany evacuating residents. Procedures are described if a patient/resident becomes ill or dies in route. Mental health and grief counselors are available at reception points to talk with and counsel evacuees. It is described whether staff family can shelter at the facility and evacuate. Transportation & Other Vendors: Establish transportation arrangements that are adequate for the type of individuals being served. Obtain assurances from transportation vendors and other suppliers/contractors identified in the facility emergency plan that they have the ability to fulfill their commitments in case of disaster affecting an entire area (e.g., their staff, vehicles and other vital equipment are not overbooked, and vehicles/equipment are kept in good operating condition and with ample fuel.). Ensure the right type of transportation has been obtained (e.g., ambulances, buses, helicopters, etc). * Train Transportation Vendors/Volunteers: Ensure that the vendors or volunteers who will help transport residents and those who receive them at shelters and other facilities are trained on the needs of the chronic, cognitively impaired and frail population and are knowledgeable on the methods to help minimize transfer trauma. * Facility Reentry Plan: Describe who will authorizes reentry to the facility after an evacuation, the procedures for inspecting the facility, and how it will be determined when it is safe to return to the facility after an evacuation. The plan should also describe the appropriate considerations for return travel back to the facility. * Residents & Family Members: Determine how residents and their families/guardians will be informed of the evacuation, helped to pack, have their possessions protected and be kept informed during and following the emergency, including information on where they will be/go, for how long and how they can contact each other. Resident Identification: Determine how residents will be identified in an evacuation; and ensure the following identifying information will be transferred with each resident: Name Social security number Photograph Note: Some of the recommended tasks may exceed the facility s minimum Federal regulatory requirements * Task may not be applicable to agencies that provide services to clients in their own homes Page 3 September 2007

14 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Survey & Certification Emergency Preparedness for Every Emergency EMERGENCY PREPAREDNESS CHECKLIST RECOMMENDED TOOL FOR EFFECTIVE HEALTH CARE FACILITY PLANNING Not Started In Progress Completed Tasks Medicaid or other health insurer number Date of birth, diagnosis Current drug/prescription and diet regimens Name and contact information for next of kin/responsible person/power of Attorney) Determine how this information will be secured (e.g., laminated documents, water proof pouch around resident s neck, water proof wrist tag, etc.) and how medical records and medications will be transported so they can be matched with the resident to whom they belong. Trained Facility Staff Members: Ensure that each facility staff member on each shift is trained to be knowledgeable and follow all details of the plan. Training also needs to address psychological and emotional aspects on caregivers, families, residents, and the community at large. Hold periodic reviews and appropriate drills and other demonstrations with sufficient frequency to ensure new members are fully trained. Informed Residents & Patients: Ensure residents, patients and family members are aware of and knowledgeable about the facility plan, including: Families know how and when they will be notified about evacuation plans, how they can be helpful in an emergency (example, should they come to the facility to assist?) and how/where they can plan to meet their loved ones. Out-of-town family members are given a number they can call for information. Residents who are able to participate in their own evacuation are aware of their roles and responsibilities in the event of a disaster. Needed Provisions: Check if provisions need to be delivered to the facility/residents -- power, flashlights, food, water, ice, oxygen, medications -- and if urgent action is needed to obtain the necessary resources and assistance. Location of Evacuated Residents: Determine the location of evacuated residents, document and report this information to the clearing house established by the state or partnering agency. Helping Residents in the Relocation: Suggested principles of care for the relocated residents include: Encourage the resident to talk about expectations, anger, and/or disappointment Work to develop a level of trust Present an optimistic, favorable attitude about the relocation Anticipate that anxiety will occur Do not argue with the resident Do not give orders Do not take the resident s behavior personally Use praise liberally Include the resident in assessing problems Encourage staff to introduce themselves to residents Encourage family participation Review Emergency Plan: Complete an internal review of the emergency plan Note: Some of the recommended tasks may exceed the facility s minimum Federal regulatory requirements * Task may not be applicable to agencies that provide services to clients in their own homes Page 4 September 2007

15 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Survey & Certification Emergency Preparedness for Every Emergency EMERGENCY PREPAREDNESS CHECKLIST RECOMMENDED TOOL FOR EFFECTIVE HEALTH CARE FACILITY PLANNING Not Started In Progress Completed Tasks on an annual basis to ensure the plan reflects the most accurate and up-todate information. Updates may be warranted under the following conditions: Regulatory change New hazards are identified or existing hazards change After tests, drills, or exercises when problems have been identified After actual disasters/emergency responses Infrastructure changes Funding or budget-level changes Communication with the Long-Term Care Ombudsman Program: Prior to any disaster, discuss the facility s emergency plan with a representative of the ombudsman program serving the area where the facility is located and provide a copy of the plan to the ombudsman program. When responding to an emergency, notify the local ombudsman program of how, when and where residents will be sheltered so the program can assign representatives to visit them and provide assistance to them and their families. Conduct Exercises & Drills: Conduct exercises that are designed to test individual essential elements, interrelated elements, or the entire plan: Exercises or drills must be conducted at least semi-annually Corrective actions should be taken on any deficiency identified Loss of Resident s Personal Effects: Establish a process for the emergency management agency representative (FEMA or other agency) to visit the facility to which residents have been evacuated, so residents can report loss of personal effects. * Note: Some of the recommended tasks may exceed the facility s minimum Federal regulatory requirements * Task may not be applicable to agencies that provide services to clients in their own homes Page 5 September 2007

16 General Emergency Supplies Checklist This checklist can be used to help you plan what emergency supplies you ll need and what quantities to buy for your household. It is a good idea to gradually buy items now so that you have at least a two-week supply of water and emergency supplies for each person in your home. Two-Week Emergency Supply Checklist Items 2 people 4 people Your quantity Check off First aid kit and instructions 1 medium kit 1 large kit Emergency radio with batteries 1 1 Lanterns, flashlights, candles 2 flashlights 4 flashlights Batteries 2 (12-packs) 4 (12-packs) Trash bags 20 bags 40 bags Barbeque pits, camping stove as needed as needed Lighter fluid and matches 2 containers/boxes 4 containers/boxes Fire extinguisher (A-B-C type) 2 2 Manual can opener and knife 1 1 Plastic food containers Zip lock bags, one-gallon size Paper/plastic eating utensils 100 sets 200 sets Warm blankets, sleeping bags 2 sets 4 sets Extra warm clothing and shoes 4 full sets 8 full sets Personal hygiene products as needed as needed Baby and/or pet supplies as needed as needed Toolkit with wrench, pliers, etc. 1 1 Utility instructions, maps, etc. 2 copies 4 copies Copies of important documents as needed as needed If possible: 2 people 4 people Your quantity Check off Cell phone with battery 1 1 Emergency cash $200 $400 Two-Week Supply of Drinking Water Number in family/group Allow 14 gallons per person Total water required x 14 gallons = total gallons

17 Food Supplies Checklist This checklist can be used to help you plan what food supplies you ll need and what quantities to buy for your household. It is a good idea to gradually buy items now so that you have at least a two-week supply of food for each person in your home. Foods That Will Not Spoil Easily Food items 2 people 4 people Your quantity Check off Flour 11 lbs 22 lbs Bread mix 11 lbs 22 lbs Sugar 1 lb 1 lb Salt (includes medical use) 2.5 lbs 5 lbs Cereal bars 28 bars 56 bars Milk powder 3 lbs 3 lbs Yeast, instant dried 3 oz 6 oz Corn meal 1 box 2 boxes Oatmeal 1 box 2 boxes Pasta 3 lbs 6 lbs Rice 2 lbs 4 lbs Beans/lentils lbs 1-2 lbs Breakfast cereals 2 boxes 4 boxes Baking soda 1 box 1 box Comfort Foods Food items 2 people 4 people Your quantity Check off Chocolate and candies as desired as desired Honey 1 jar 2 jars Hot chocolate mix as desired as desired Fruit roll-ups and other snacks as desired as desired Packaged cookies as desired as desired

18 Food Supplies Checklist Foods That Last One Year Food items 2 people 4 people Your quantity Check off Canned vegetables 14 (14oz) cans 28 (14oz) cans Canned milk 4 (14oz) cans 8 (14 oz) cans Canned casseroles/meats 4 cans 8 cans Baked beans, spaghetti 4 (420g) cans 8 (420g) cans Canned soups 8 (420g) cans 16 (420g) cans Pasta sauce 2 jars 4 jars Canned fish 4 (200g) cans 8 (200g) cans Canned fruit 14 (400g) cans 28 (400g) cans Instant meals as desired as desired Instant puddings as desired as desired Dried fruit 2 lbs 4 lbs Dried vegetables 1lb 2 lbs Soup mixes 6-8 packets packets Use By Expiration Date Food items 2 people 4 people Your quantity Check off Crackers 7 packets 14 packets Energy bars/biscuits 4-6 packets 8-12 packets Nuts 2 lbs 4 lbs Soy milk 1 box 2 boxes Peanut butter 2 jars 4 jars Jelly 7 packets 14 packets Sports drinks 2 cases 4 cases Baby formula as needed as needed Baby food as needed as needed Pet food (if needed) 2-week supply 2-week supply Coffee (depends on usage) 1 medium jar 1-2 large jars Tea (depends on usage) bags bags

19 Canadian Centre for Emergency Preparedness Risk Assessment 1=Low 3=Med 5=High Applicable? Risk Plans Required Threat Yes/No Probability Vulnerability Impact Factor Emeg BCP Crisis Human Error: Operation 0 Power Outage--External 0 Power Outage--Internal 0 Power Flux 0 Chemical Spill - Internal 0 Chemical Spill - External 0 Central Computer Equipment Failure 0 Water Leak/Plumbing Failure 0 Equipment Failure 0 Hostage Taking 0 Bomb Threat 0 HVAC Failure/Temperature Inadequacy 0 Death of Key Staff 0 Epidemic 0 Flooding 0 Fire: Internal--Catastrophic 0 Fire: Internal--Major 0 Fire: Internal--Minor 0 Telecommunications Failure - Voice 0 Telecommunications Failure - Data 0 Labor Dispute/Strike 0 Tornado 0 Hurricane/Typhoon 0 Snowstorm/Blizzard 0 Ice Storm 0 Thunder/Electrical Storm 0 Application Software Failure 0 Earthquake - Major Damage 0 Earthquake - Minor Damage Copyright 2000, Canadian Centre for Emergency Preparedness

20 Source: the California Primary Care Association s Clinic Emergency Operations Plan, Appendix D.2 MANAGEMENT OF ENVIRONMENT HAZARD SURVEILLANCE/RISK ASSESSMENT REPORT FORM Date: Building: Program Hazard Surveillance/Risk Assessment Item Comments Safety Management 1. Are grounds clean & free of hazards? 2. Are floors clean, dry, in good repair, & free of obstruction? 3. Are mechanisms for access (i.e. ramps, handrails, door opening mechanisms, etc.) operational? Security Management 4. Is the parking area free of potholes or other hazards? SUBTOTALS 1. Are doors functioning & locked as appropriate? 2. Are medical records centrally located and accessible ONLY to authorized personnel? 3. Are alarms functioning, tested, and maintained in accordance with manufacturer's specifications? 4. Are systems/mechanisms in place to quickly notify officials or other staff quickly in the event of a security related problem? SUBTOTALS PROGRAM TOTAL: PROGRAM TOTAL:

21 Source: the California Primary Care Association s Clinic Emergency Operations Plan, Appendix D.2 Program Hazard Surveillance/Risk Assessment Item Comments Hazardous Materials & Waste Management 1. Are OSHA Hazard Communication and Exposure Control Documents Available? 2. Have all biohazard and toxic substances present been identified? 3. Are Materials Safety Data Sheets (MSDS) quickly available for all identified toxic substances? 4. Are all waste contaminated with blood/body fluid considered and handled as infectious? 5. Are sharps containers puncture resistant and in accordance with require safety standards? 6. Are sharps and disposable syringes placed in approved sharps containers? 7. Are all engineering, personal protective equipment & workplace controls in effect? SUBTOTALS PROGRAM TOTAL: Emergency Preparedness Management 1. Is there an updated disaster plan in the department? 2. Has a non-fire related emergency drill been performed in the past six months? 3. Is staff aware of at least three different types of potential non-fire emergencies and their role in eliminating or reducing the risk of patients, staff and property? 4. Is staff aware of the primary and secondary exits from the facility?

22 Source: the California Primary Care Association s Clinic Emergency Operations Plan, Appendix D.2 Program Hazard Surveillance/Risk Assessment Item Comments Life Safety Management Medical Equipment Management SUBTOTALS 1. Is the evacuation plan posted and can staff demonstrate knowledge of the plan? 2. Are fire extinguishers located in accordance with NFPA standards? 3. Are fire extinguishers inspected monthly and documented on/near the extinguisher? 4. Are smoke/fire alarm systems functioning, tested, and maintained in accordance with manufacturers specifications? 5. Are exit hallways well lit & obstacle free? 6. Is emergency exit lighting operational and tested in accordance with NFPA standards? 7. Are fire/smoke doors operating effectively? 8. Are no smoking policies in effect and signs are posted appropriately? SUBTOTALS 1. Is there a unique inventory of all medical equipment in the facility? 2. Are all equipment evaluated & prioritized prior to use? 3. Has all equipment been tested/maintained according to manufacturer's specifications? PROGRAM TOTAL: PROGRAM TOTAL:

23 Source: the California Primary Care Association s Clinic Emergency Operations Plan, Appendix D.2 Program Hazard Surveillance/Risk Assessment Item Comments Utility Management 4. Are maintenance records complete, are they capable of tracking the maintenance history of a particular piece of equipment, and do they record the results of both electrical safety as well as calibration, as appropriate? 5. Are systems/mechanisms in place to respond appropriately to a medical equipment failure? SUBTOTALS 1. Are the lights, emergency lights, and power plugs operational and in working order? 2. Does the water/sewage system appear to be working properly and has the water quality been tested within the past year? 3. Is the telephone system operational? 4. Has the HVAC system been inspected in accordance with manufacturers specifications and have the filters been checked quarterly? 5. Are fire suppression (sprinkler) systems checked at least once a year, or as appropriate by a qualified individual? 6. Are shut-offs for all utility systems clearly marked, & accessible for all staff in the event of an emergency? 7. Are systems/mechanisms in place to respond in the event of a failure of any utility system? SUBTOTALS PROGRAM TOTAL: PROGRAM TOTAL:

24 Source: the California Primary Care Association s Clinic Emergency Operations Plan, Appendix D.2 Program Hazard Surveillance/Risk Assessment Item Comments Infection Control Monitoring Issues 1. Is all staff utilizing Universal Precautions (i.e. utilizing appropriate PPE, handwashing, etc.) in the performance of their job duties? 2. Are cleaning solutions secured, mixed, and utilized appropriately throughout the facility? 3. Are potentially "infectious patients" aggressively identified and processed in a manner which would minimize the risk of infection of staff and other patients? 4. Can staff intelligently describe their role in infection control within the organization? SUBTOTALS PROGRAM TOTAL: Other Key Safety Monitoring Issues 1. Are Utility Rooms locked, clean and clear of debris? 2. Are Storage Rooms secure, clean, and free of flammable? 3. Are Emergency Carts present, as appropriate, fully stocked, and checked per schedule? 4. Are all medications, including samples, secured and accounted for by lot number? SUBTOTALS PROGRAM TOTAL:

25 Source: the California Primary Care Association s Clinic Emergency Operations Plan, Appendix D.2 Program Hazard Surveillance/Risk Assessment Item Comments OVERALL ASSESSMENT TOTALS TOTAL: SCORING LEGEND: 1 = Outstanding 2 = Good 3 = Satisfactory 4 = Marginal 5 = Unsatisfactory Inspected Conducted By: Reports Noted: Date: Safety Officer

26 Source: California Primary Care Association Clinic Emergency Operations Plan Appendix D.3 (modified) STRUCTURAL AND NON-STRUCTURAL HAZARD MITIGATION CHECKLIST The following are suggested checklists (list is not all inclusive) of recommended structural and nonstructural mitigation actions: Structural Mitigation Structural mitigation is reinforcing, bracing, anchoring, bolting, strengthening or replacing any portion of the building that may become damaged and cause injury such as: exterior walls (e.g., use a wind resistant design for tornados or windstorms) exterior doors (e.g., non-combustible materials for wildfires or urban fires) exterior windows (e.g., use shutters on windows for tornados or windstorms) foundation (e.g., brace, anchor or bolt the facility for earthquakes) exterior columns/pilasters/corbels (e.g., steel or concrete columns) roof (e.g., use non-combustible materials for wildfires or urban fires) STRUCTURAL Earthquakes anchor/brace or bolt the facility to its foundation and reinforce any portion of the exterior of the facility that may cause injury. Floods and flashfloods elevate and reinforce the facility but ultimately avoid a floodplain location. Landslide and mudflow build retaining walls on slopes. Build masonry walls to direct the mudflow around the facility. Bolt the foundation and reinforce the walls of the facility. Tsunami elevate at-risk coastal facilities. Even the strongest building can be damaged by a powerful tsunami. Wildfire and urban fire use fire resistant materials (e.g., non-combustible roofing material) on the exterior of the facility. Tornado follow local building codes to use a wind resistant design for your facility. Dam failure reinforce and flood-proof the facility.

27 Source: California Primary Care Association Clinic Emergency Operations Plan Appendix D.3 (modified) Nonstructural Hazard Mitigation Nonstructural mitigation reduces the threat to safety posed by the effects of disasters on such nonstructural elements as building contents, internal utility systems, interior glass and decorative architectural walls and ceilings. These actions involve identifying nonstructural fixtures and equipment, which are vulnerable to a disaster and which are either essential to continued operations or a threat to public safety. Nonstructural mitigation is: Retrofit refers to various methods for securing nonstructural items. Retrofitting methods are bracing, securing, tying down (tethers or leashes), bolting and anchoring. Replace replacing the item with a new one that is resistant to the hazard. Relocate moving items from a hazardous location to a non-hazardous one. Backup Plan if there is concern that an essential service will be disrupted, provide for backup service it is planning for the consequences of failure. Nonstructural mitigation includes all contents of the structure that do not contribute to its structural integrity such as: Systems and elements which are essential to the facility operations Emergency power generating equipment - plumbing, HVAC Fire protection system - fire sprinklers and distribution lines, emergency water tank or reservoir Medical equipment - respirators and life support, refrigeration units to store pharmaceuticals. Food storage and preparation equipment keeping food safe to eat (i.e. refrigeration, stoves and ovens) Hazardous materials restrain chemicals on shelves, containers stored on braced storage rack or tall stacks, gas tanks with flexible connections, gas tank legs anchored to a concrete footing or slab. Non-essential elements whose failure could compromise facility operations, such as: suspended lights and ceilings partitions interior doors furniture and contents - book shelves, file cabinets, etc.

28 Source: California Primary Care Association Clinic Emergency Operations Plan Appendix D.3 (modified) NONSTRUCTURAL Brace light fixtures and other items that could fall or shake loose. Secure top and bottom of compressed gas cylinders with a safety chain. Store containers of hazardous materials on braced storage rack or tall stacks and restrain the containers with a restraining device such as metal or wire guardrails. Secure any desktop equipment such as computers, TV monitors, typewriters, printers, etc. Install shatter resistant protective film or blinds on windows to prevent glass from shattering onto people or install safety glass. Ensure that any equipment with piping be a flexible connection (e.g., gas pipes, water tanks, sprinkler piping, water heaters) Anchor any tall, unsecured furniture to the wall and/or to each other. Ensure that cabinets have positive catching latches. Secure suspended ceilings with diagonal bracing wires. Hang heavy objects away from workstations and beds. Secure any larger equipment such as copiers or heavy machinery to the floor or use tethers and attach to the wall. Cross brace tall storage racks in both directions or, for racks significantly taller than wide, secure with anchor bolts connected to the concrete slab. Ensure the main breaker or fuse box and the utility meters are elevated above the anticipated flood level of your facility to prevent damage. Secure one-of-a-kind equipment of high value from overturning or sliding.

29 Hazard Vulnerability Worksheet The purpose of this worksheet is to provide a format for each facility to score yourself in each of 13 various areas of vulnerability. The total of these scores will provide a "vulnerability score" that can be used to allow the administrator the ability to evaluate their facility for potential mitigative actions that can reduce that vulnerability. Please note that the Federal ASPER Grant that is providing your facility with grant funds for emergency preparedness activities REQUIRES that each facility complete this vulnerability assessment. Step 1: Please save this document to your computer. Step 2: Complete the assessment. Step 3: Save the document again and attach it to an and send it to me at deb@uthca.org. I need to receive your completed assesment in my office by 5:00 pm on Friday, April 4th. Please place the appropriate numeric score in the yellow shaded area marked score in the left column for each hazard. Then provide a cumulative score in the green Total Score Box at the bottom of the assessment. Date: Enter the date this worksheet was completed. Facility Name: Facility Address: Facility City and State: Facility Zip Code: Name of contact completing this Assessment: Contact phone number: Facility Type: Scoring the Facility's Vulnerability Facility Type: Which of the following classifications does this facility fall within? Please highlight one. SNF 100 plus beds SNF/ICF beds SNF/ICF with 49 or less beds ICF/MR

30 Subject to Temperature change: 0 This facility is not subject to damage from extreme temperature change. 1 This facility is located in area of mild temperature changes. 2 This facility is located in area of moderate temperature changes. 3 This facility is located in area of extreme temperature changes. Score Subject to Flood, Wind or Weather Damage: 0 This facility has no history of flood, wind, or weather damage. 1 This facility has had at least one incident of flood, wind or weather damage. 2 This facility has had from 2-10 incidents of flood, wind, or weather damage. 3 This facility has had greater than 10 incidents of flood, wind or weather damage. Score Subject to Earthquake: 0 This facility is not located in a known seismic zone. 1 This facility is subject to minor damage from an earthquake. 2 This facility is subject to major damage from an earthquake. 3 This facility is subject to major damage, extensive injuries and loss of operations from an earthquake. Score Vulnerable to Power Outage: 0 This facility has an onsite generator capable of supporting the entire facility for 72 hours. 1 This facility can lose power but an onsite generator will support only part of the facility. The building is configured to accept a dedicated portable generator that is readily available. A power outage at this facility will cause some minor difficulties. 2 This facility can lose power but an onsite generator will support only part of the facility. The building is configured to accept a portable generator if one is available. A power outage at this facility will cause some major difficulties. 3 This facility has no emergency power capabilities and a power outage may create major difficulties and loss of operations. Score

31 Vulnerability to Lightning: This category is intended to score the facility for the effects of the electrical surge from a lightning strike. 0 This facility is not particularly vulnerable to lightning due to its location, construction, profile or the fact that there are protective systems in place. 1 This facility is vulnerable to lightning, but equipment on site is not of a nature that disruption from a strike would create a problem or do major damage to critical systems. 2 This facility is vulnerable to lightning, has critical systems and/or equipment, but protective measures have been taken to lessen the likelihood of system failure from a strike. 3 This facility is vulnerable to lightning and a strike would create a major problem and/or critical systems will go down. No protective systems are in place. Score Dependent on Water Supply: 0 This facility can operate without normal water supply for over 72 hours. A reserve water system is located onsite. 1 This facility can operate without normal water supply for between 24 and 72 hours. After that period the facility will experience difficulties. 2 This facility must have a normal water supply within 24 hours or the facility will not be able to function. 3 This facility must not lose a normal water supply. Score Vulnerable to Sewer System Outage: 0 This facility is not vulnerable to a sewer outage. 1 A sewer system outage would cause minor problems for this facility. 2 A sewer system outage would cause moderate problems for this facility. 3 A sewer system outage would cause major problems for this facility. Score Dependent upon Communications: 0 This facility is not vulnerable communications equipment failure. 1 This facility could lose communications capability without major problems as long as that capability is restored within hours. 2 This facility will experience major problems if communications capability is not restored within the first 24 hours. 3 This facility must not lose communications capability. Score