Forrest General Hospital Emergency Operations Plan

Revised January 2014 Approved September 2007 Forrest General Hospital Emergency Operations Plan License #11-141 Licensure year: January 1, 2013 December 31, 2013

FORREST GENERAL HOSPITAL ALL HAZARDS EMERGENCY OPERATIONS PLAN BASE PLAN - Section 1 APPROVED SEPTEMBER 2007 REVISED JANUARY 2014

SECTION I BASE PLAN

Forrest General Hospital All Hazards Emergency Operations Plan Base Plan Section 1 Table of Contents PLAN APPROVAL 1 Hospital Facility Profile 2 Record of changes 4 STRATEGIC NATIONAL STOCKPILE 7 Purpose 7 COORDINATION OF PLANNING WITH PUBLIC HEALTH 7 REQUESTING THE SNS 8 ACQUIRING THE SNS 9 DISTRIBUTION OF SNS MEDICATIONS 9 SECURITY 10 PUBLIC INFORMATION 10 DEMOBILIZATION 11 REFERENCES 12 Points Of Contact 13 RECEIVING SHIPMENTS 13 After Hours Shipments 13 Receiving Direct Shipments 13 Emergency Pickup And Transportation 14 STORAGE OF SNS MATERIALS 14 PURPOSE AND SCOPE 14 GOALS AND OBJECTIVES 14 PERFORMANCE STANDARDS & EVALUATION 15 PLAN INTEROPERABILITY 16 Community Based Planning 16 Manual Layout 17 Plan Approval and Revisions 20 Plan Accessibility 21 RESPONSIBILITIES AND AUTHORITY 21 Responsibilities 21 Administration 21 Medical Staff 21 Staff, Employees and Personnel 22 Authorities 22 COORDINATING STRUCTURES 22 HICS Command Structure 22 Command Integration and Interoperability 23 Department Directors / Managers 24 SPECIFIC GUIDANCE IN DISASTERS 24 Preparedness & Planning 25 Hospital Leaders and Medical Staff 25 Emergency Management Committee 26 Review / Revision 26 Drills & Exercises 26

Hazards Vulnerability Assessment Evacuation and Patient Transfers Vehicular Access to Emergency Services Elevators Operations in Disasters Helicopter Landing and Departing Access Control Sheltering Policy & Dependent Care Alternate Care Sites Management of Resources and Assets IMPLEMENTATION OF PLANS NIMS, Introduction to Implementation National Incident Management System (NIMS) FGH NIMS Compliant NIMS Essential Elements and FGH Planning HICS and Roles in All Hazards Emergency Operations Plan INTERNAL CODES MEDICAL CONTROL AND MEDICAL STAFF ASSIGNMENTS PRIORITY AREAS Triage Area Priority I Area Emergency Services Priority II Area Radiology Holding Priority III Area Employee Health Services CALL BACKS POST EMERGENCY MANAGEMENT & RECOVERY Measurements for NIMS Complance Criteria Checklist for Activating FGH Incident Command Center

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-1 Forrest General Hospital License # 11-141 APPROVAL OF FORREST GENERAL HOSPITAL ALL HAZARDS EMERGENCY OPERATIONS PLAN Evan Dillard, President Date Wayne Landers, Director Department of Public Safety Date Mississippi State Department of Health Office of Emergency Preparedness and Response District Level Betty Kreider, District Planner Date Emergency Preparedness Nurse Date Mack Strider Emergency Response Coordinator Date State Level EOP Program Director Date Local Emergency Management Agency Terry Steed, Director The Emergency Management District Date

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-2 Hospital Facility Profile Facility Name: Forrest General Hospital Address: 6051 US Highway 49 Hattiesburg, MS 39401 County: Forrest Phone: 601-288-7000 Fax: 601-288-4370 Emergency Phone: 601-288-4345 Owner/Corporation: SAME Address: Phone: Secondary Phone: Emergency Phone: Facility Administrator: Evan Dillard, President Address: 6051 US Highway 49 Hattiesburg, MS 39401 Phone: 601-288-6069 Secondary Phone: 601-288-7000 Emergency Phone: 601-297-6069 Emergency Operations Plan Coordinator: V. Wayne Landers Address: 6051 US Highway 49 Hattiesburg, MS 39401 Phone: 601-288-1005 Secondary Phone: 601-288-4345 Emergency Phone: 601-549-2685 Licensed Facility Bed Capacity: 512 Average Daily Census: 360

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-3 Long Term Care Services: (e.g., specialty services or units) Patients in Care Provide the approximate number of individuals within the facility s care who have the following disabilities and/ or dependencies: Disability or Other Challenges Alzheimer s, dementia or cognitive impairment: 32 Confined to bed: 32 Blind or low vision: 112 Require 24-hour constant care: 60 32 Deaf or hearing impaired: Chronic condition (please specify): 180 Speech impaired: 16 Other (please specify): Limited mobility or difficulty walking: 128 Dependency Dialysis: 20 Insulin: 109 Walker/cane/scooter/wheelchair: 100 Ventilator: 24 Oxygen: 135 Other (please specify): Service animal: Other machine dependent:

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-4 ALL HAZARDS EMERGENCY OPERATONS PLAN RECORD OF CHANGES Submit recommended changes to this document to the: Emergency Management Committee; Wayne Landers, Chair Any changes recommended by the Emergency Management Committee such as training materials, Opportunities for Improvement in response to annual exercises or actual events, equipment needs and purchases, evaluations and corrective processes are documented in the monthly minutes of the Emergency Management Committee. Change Number Date of Change 1 01/09 2 03/09 3 04/09 4 05/09 5 07/9 6 08/09 Description of Change Change of plan name from All Hazards Disaster and Emergency Plan to All Hazards Emergency Operations Plan. Base Plan 11.C.1 Base Plan 11.D.1 Dept. Annex G: HR no changes Incident Annex J Radiological Events no changes JAS Operations no changes NIMS Compliance update Dept. Annex 1.S.3 title change Dept. Annex G.1.L Respiratory Care Dept. Annex G Dialysis - approved Dept. Annex: Annex G.1.C Cancer Center no changes Annex G.1.AA Patient Accounts no changes Incident Annex: Annex I Pandemic Flu/Infectious Disease title change Annex B Bomb Threat no changes Annex C Civil Disturbance no changes Annex E Hazmat/Decon no changes Dept. Annex: Annex F Public Information no changes Annex G Print Shop no changes Annex G Food and Nutrition no changes Annex G Biomedical no changes Annex G Engineering no changes Annex G Employee Health no changes Annex G Cath Lab no changes Annex G HC/Hospice no changes Annex O Pet Care no changes Annex I Pandemic Flu or Infectious Disease changes approved Incident Annex: A Bioterrorism title change approved I Pandemic Flu/Infectious Disease no changes G Code Pink - 1; 3.A.4; 3.A.9; 3.A.12; 9 Dept. Annex G Health Information Mgmt. changes approved Initials

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-5 Change Number Date of Change 7 09/09 8 10/09 Description of Change Base Plan: 3.B.1; 3.B.2; 4.A.9; 6.B.2.b.5.f; 6.B.3; 6.B.4; 7.B.8; 7.B.9; 8.3.k; 8.4; 11.D.2.a; 12.B ESF Annex no changes Dept. Annex: Annex G Administration no changes Annex G Communications no changes Annex G Public Safety no changes Annex G Morgue no changes Annex D Telecommunications no changes Incident Annex: Annex F Hostage Situation Annex K Terrorism/Other no changes Annex N VIP no changes HVA 2009 HVA approved Dept. Annex: Annex G Pine Grove changes approved Annex G Finance no changes Annex G Central Transport no changes 9 11/09 Base Plan - #7.C Management of Resources & Assets 10 01/10 11 02/10 12 03/10 Inserted Continuity of Operations in Dept. Annex H Inserted VIPR Appendices pg. 10 Inserted SMARTT Appendices pg. 13 Inserted SNS Appendices pg. 15 Inserted Mgmt of behavioral health pts. Annex E Inserted Mgmt of mental health pgs. Annex E Inserted Record of Changes Base Plan Inserted Approval and Signature page Base Plan Updated Community based planning -4.A.3 Base Plan Updated Plan approval and revisions process Base Plan 4.C.2 Base Plan Priority areas Annex G Education will not be involved in childcare Annex A Vice President of Clinical Operations to Chief Clinical Operations Officer Annex G Material Management- updated Annex G - Purchasing - updated 13 04/10 JAS Operations - updated 14 05/10 Added Satellite Radio & cell phone operation guide Added Districts 8 & 9 EMC satellite radio roll call schedule to 15 06/10 Incident Annex Code Pink - updated 16 07/10 17 08/10 Dept. Annex G Food & Nutrition updated Dept. Annex G Education updated Dept. Annex G Marketing & Communications updated Dept. Annex G Insurance Operations updated Dept. Annex G Patient Registration updated 18 09/10 Incident Annex Hurricane (controlled access) updated 19 10/10 20 11/10 Updated HVA Section 2 Appendices 21 03/11 Added license Number to approval sheet 22 04/11 Updated Incident Annex/Information Services Initials 23 06/11 Updated Dept. Annex/G/Volunteer Services Updated Incident Annex H/Code Pink

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-6 Change Number Date of Change 24 07/11 25 08/11 Description of Change Added Walthall and Jeff Davis to organization chart Minor changes made to Dept. Annex/HIM; Food and Nutrition; Employee Health Updated Dept. Annex/Morgue Added Code Silver (active shooter) to Incident Annex 26 09/11 Received approval letter from MSDH 27 10/10 28 11/10 29 01/12 30 02/12 Updated Base Plan with minor changes Inserted NDMS partner hospitals list Incident Annex N Trauma with minor changes ICC Job Action Sheets minor changes Dept. Annex G Telecommunications - Updated emergency phone #s, 31 03/12 minor changes to Finance. Incident Annex L minor changes 32 04/12 minor changes to Dept. Annex G Labs minor changes to incident Annex Fire/Smoke 33 05/12 Minor changes 6to incident Annex B Bomb Threat (phone #) 34 06/12 Received 2012 MSDH letter of approval 35 08/12 36 37 04/13 2012 HVA added Added updated CEMP Updated Utility Failure - Loss of Medical Gases Updated Incident Annex /Annex E Fire/Smoke Monitored by Simplex Grinnel Individual orientation @ buildings other than main hospital Location of fire fighting equipment Other minor changes Updated SMARTT Departmental Annex G/Patient Care Services Updated contact names and #s Updated Incident Annex/Annex P - Mini Disaster 38 05/13 Updated contact #s in Departmental Annex/Annex G/Information Services 39 06/13 40 07/13 41 08/13 42 09/13 43 10/13 HVA updated 44 12/13 Updated Departmental Annex G/Laundry Updated Departmental Annex G/Volunteer and Guest Services- minor changes Updated contact information -Base Plan POCs Added Plan Accessibility to Base Plan Added Talal Chohan as the Radiation Officer to Incident Annex/ Radiological Events Minor changes to Base Plan/Priority areas Minor changes to Dept. Annex G Emergency Services Initials

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-7 STRATEGIC NATIONAL STOCKPILE (R 01/10) Purpose The Strategic National Stockpile (SNS) is a federal resource used to provide medicine and medical supplies to protect the public in the event of a public health emergency as a result of an act of terrorism or a large-scale natural or human-caused disaster that is so severe that local and state resources are inadequate or become overwhelmed. If such an event should affect this community, Forrest General Hospital may need to utilize SNS resources to treat patients and/or to provide prophylaxis to both patients and facility staff. The purpose of this annex is to outline procedures for coordinating with public health to obtain medications and needed medical supplies from the SNS during a public health emergency. What is the SNS? The SNS consists of antibiotics, chemical antidotes, anti-toxins, life-support medications, IV administration, airway maintenance supplies and medical/surgical items. Medications and medical supplies are intended to support treatment of ill patients and mass prophylaxis for those exposed but not yet symptomatic. Once federal, state and local authorities agree that state and local resources have or will soon become overwhelmed, SNS supplies can be delivered to the state. Once the SNS supplies arrive in Mississippi, the Mississippi State Department of Health (MSDH) is responsible for managing the supplies and distributing them to affected communities and facilities across the state. Local governments will play a vital role in providing support to state SNS operations such as the use of facilities, resources, staff and volunteers to help with the distribution of medications and/or medical supplies to target populations. Healthcare facilities play a major role by treating those who are ill and providing medications to medical staff and their families to prevent them from becoming ill. Coordination of Planning with Public Health (R 07/13) Planning for the SNS must be coordinated with MSDH. Planning for mass prophylaxis of hospital staff: The first step in coordinating this planning is to register with the state by completing the Strategic National Stockpile (SNS) and Pandemic Influenza Programs Provider Enrollment MSDH Form #255. This form can be obtained on the MSDH website at www.healthyms.com or from any district health office. This form was submitted to the MSDH District Surveillance Nurse on January 12, 2010. MSDH coordinates with registered facilities in planning for receiving the SNS. MSDH will also provide training including how the treatment algorithms and standing orders contained in the MSDH SNS Plan (plan is located on the MSDH website at www.healthms.com) are to be used by healthcare personnel in the distribution of medications from the SNS. The Director of Pharmacy will work with MSDH to coordinate planning and training of staff for possible SNS activation. The MSDH point of contact for Forrest General Hospital SNS planning is the MSDH District Surveillance Nurse, Debbie Nielsen, Surveillance Nurse, District VIII, MSDH; 16 Office Park Drive, Suite 5, Hattiesburg, MS 39402; office 601-

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-8 271-6099 or cell 601-466-8502. MSDH also requires a coordinating physician be identified from the facility to oversee the dispensing of medications and/or administration of vaccine(s). The physician is not required to be on-site, but staff will be required to work under his or her direction. The Coordinating Physician for Forrest General Hospital is Dr. Steven Farrell. Planning for receiving assets for treatment of ill patients: MSDH does not require completion of the Provider Enrollment Form for healthcare facilities to receive SNS assets for the treatment of ill persons. MSDH will need case count, epidemiologic, intelligence and inventory information from treatment centers to support strategic decisions. MSDH will need contact information for people at the treatment center responsible for providing periodic case counts. Requesting the SNS The SNS is a federal resource. As with all federal resources, it cannot be requested unless response to the incident is anticipated to exceed local and state resources. If Forrest General Hospital encounters a situation where patient demand is anticipated to exceed available resources, the Director of Pharmacy or the Director or Public Safety should communicate this to The Emergency Management District; 601-544-5911 or 601-544- 5912. If local and regional resources are not sufficient to supply the increased demand, the request will be forwarded to the state Emergency Operations Center (EOC) at the Mississippi Emergency Management Agency, which will assess the situation. If indicated by the event, MSDH will request the SNS assets from the Centers for Disease Control and Prevention (CDC). The healthcare facility will need a plan to request re-supply of SNS assets. This plan should include: Communications plan that includes staff assigned (title of staff position) to request resupply, contact information for the county emergency management office and local and state public health offices, and any additional numbers that would be provided during an incident. Provision to MSDH of up-to-date information on case count, epidemiologic, intelligence and inventory information from treatment centers to support strategic decisions. Provision to MSDH of number of staff and/or staff family members for whom there has been insufficient distribution of prophylactic regimens. Detailed information for product description and quantities related to specific requests.

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-9 Acquiring the SNS If the situation necessitates the need for the SNS, the Director of Pharmacy will coordinate with MSDH for the receipt of SNS supplies. To some extent, circumstances will drive the response and dictate how supplies will be received. A representative from Forrest General Hospital might be asked to pick up SNS supplies from a health department pointof-dispensing (POD) site or another drop site in the county/city. If so, Forrest General Hospital will need to provide MSDH with the name of the healthcare representative designated to pick up the medications and/or medical supplies prior to pick up. Upon arrival at the designated location, the representative will be asked to present two forms of identification; one form of identification issued by Forrest General Hospital and one form of photo identification issued by the state (e.g., driver license). The representative will sign for all medications and/or medical supplies received. If there is a discrepancy between the order and what was received, the staff member who is receiving the supplies of the healthcare facility must notify the MSDH Command Center by phone at (601) 576-8085, as instructed in the packet of information received with the shipment. Two methods for acquiring/receiving SNS assets include: 1) Direct shipment to facility, and 2) Healthcare representative pick-up from a predetermined health department POD or other drop site in the county/city. Healthcare facility (HCF) requirements for receiving for direct shipment: Plan for receiving SNS assets to include: Day and night point of contact (in triplicate) who has authority to order and receive materials and sign for controlled substances Identification for receipt of SNS delivery (e.g., building A, rear loading dock, south entrance, etc.) Adequate material handling equipment required to off-load and stage large pallets; if a loading dock is not available, the facility should ensure plans include how to off-load by hand HCF requirement for acquiring SNS assets from health department POD or drop site: As stipulated above Distribution of SNS Medications Distribution of medications and/or administration of vaccinations from the SNS must follow the same algorithms for prophylaxis and standing orders contained in the MSDH SNS Plan or provided by MSDH with the vaccine. These algorithms will be provided to Forrest General Hospital in the SNS supplies received and through MSDH guidance issued to healthcare facilities and medical providers. The Patient Care Services personnel or Director of Pharmacy coordinating at Forrest General Hospital will oversee the distribution of SNS medications to patients. The Employee Health personnel of the healthcare facility will coordinate the distribution of the SNS medications to staff and their families.

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-10 Health information forms provided by MSDH (either hard copy or electronic copy) must be completed to receive medications and/or vaccines from the SNS. These forms must be returned to MSDH within 48 hours for patient tracking. The pharmacy staff or Employee Health will coordinate the collection of these documents and ensure they are received by MSDH within the proper timeframe. Forrest General Hospital may not charge patients, staff and/or their families for medications/vaccines or any supplies received from the SNS. Utilization of medications for the treatment of ill persons, although accompanied by medical guidance from MSDH and interim guidance from federal partners, is ultimately up to the attending physician. There are no treatment algorithms. Information about treatment regimen(s) should be captured as part of the healthcare facility s standard Medical Administration Record (MAR), which is standard medical practice, not a stipulation of distribution of the SNS. Healthcare facilities: Security Must have a plan to store assets under appropriate medical and pharmaceutical laws and regulations Must have an inventory plan Must not charge for assets Heightened security measures may be needed as a result of the events leading up to activation of SNS plans. Circumstances may lead some individuals to take unlawful measures to try to secure SNS assets for themselves and/or others. Adequate security measures must be in place to ensure SNS assets received by Forrest General Hospital are secure and to reduce any unnecessary risk to staff transporting or dispensing the medications. The Forrest General Hospital Department of Public Safety Campus Police will take appropriate measures to coordinate security including initiating the access control or lockdown procedures as necessary. Public Information During SNS activation, MSDH will activate its risk communication plan. Guidance will be communicated to the general public including the nature of the public health threat, where state operated point-of-dispensing (POD) sites will be located and who should go there. In addition, information will be provided regarding symptoms of infection and/or contamination and who should seek medical attention. Any public information messages released to the media from Forrest General Hospital should be consistent with the message issued by the state to avoid confusion and panic in the general public. The Public Information Officer and the Marketing and Communications Department will coordinate any information released to the public with the Emergency Management District and/or Joint Information Center (JIC).

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-11 Demobilization As SNS operations conclude, MSDH will provide specific instructions to healthcare facilities regarding what to do with unused supplies. The pharmacy staff will coordinate with MSDH in the final disposition of these supplies. Within a week of demobilization of SNS operations, Forrest General Hospital staff will conduct a debriefing to discuss lessons learned from the incident. The lessons learned identified in the debriefing will be used to update and improve the facility s SNS Annex. The Emergency Management Committee of the healthcare facility will update and revise plans accordingly and cooperate with MSDH in any after-action planning discussions or meetings.

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-12 References Mississippi State Department of Health, Plan for Receiving, Distributing, and Dispensing the Strategic National Stockpile Assets: www.msdh.state.ms.us/msdhsite/indes.cfm/44,1136,122,154,pdf/snsplan2008%2epdf Centers for Disease Control and Prevention, Strategic National Stockpile website: www.bt.cdc.gov/stockpile/ Attachments Attachment 1: SNS Planning Checklist for Healthcare Facilities

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-13 Attachment 1 (R011/13) Primary Point of Contact (POC) (24/7) Name and contact information: Pharmacy Department - 601-288-4213 FOR MEDICATIONS: Teresa McDaniel - 601-288-1485 tcmcdaniel@forrestgeneral.com Fax 601-288-4163 Cell 601-466-4187 Secondary POC (24/7) Name and contact information: FOR MEDICATIONS: Billie Ruth Blakeney, Operations Coordinator 601-288-4177 Fax 601-288-4163 Maurice Warren, Pharmacy Buyer 601-288-4187 Mwarren@forrestgeneral.com Ship to Address (NO P.O. Boxes): Forrest General Hospital 6051 US Hwy 49 South Hattiesburg, MS 39401 FGH Receiving # - 601-288-1916 Receiving After Hours Shipments: Forrest General Hospital can receive medications at any time. The pharmacy department is open 24 hours/7 days a week. During normal operations the Materials Supply Receiving Department operates from 8:00 a.m. until 5:00 p.m. Emergency shipments after hours can be coordinated by calling the Material Management on-call phone 601-297-0181. Other emergency contacts: Doris Vaughn 601-550-3825 Receiving Direct Shipments: Forrest General Hospital Materials Management Department operates a full services receiving dock. Contact numbers are: Michael Reed 601-582-3703 601-270-1267 Anita Carter 601-434-2773 Stacie Strebeck - 601-408- 2273

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-14 Emergency Material Pickup and Transportation: The Forrest General Hospital Material Management Department maintains one large truck, a van van and pickup trucks for material transport. Pickup and transportation of materials during an emergency will be arranged and provided as needed. Storage of Strategic National Stockpile Materials: For medications: Forrest General Hospital has ample storage space for both refrigerated and nonrefrigerated medications. Materials Management maintains a large area for receiving, storing and delivering materials to various departments as needed. **If shipments are requested, facilities could be responsible for costs of returning shipments to MSDH. A documentation of the understanding that persons cannot be charged or billed for supplies received from SNS (state or federal) must be completed at the time of receiving SNS materials.** Facility Security Plan: The Forrest General Hospital Department of Public Safety Campus Police provides security for Forrest General Hospital. If necessary the department would activate its emergency staffing plan. This plan provides for increased staff as needed by suspending off days and paid time off as necessary. Various other emergency operations plans are activated as needed including controlled Access Plan or the Facility Lockdown Plan. 1. PURPOSE AND SCOPE (R11/12) A. Purpose The All Hazards Emergency Operations Plan for Forrest General Hospital involves assessing and measuring to improve performance of all employees in disaster situations. The daily functions of prevention and intervention are centered on an integrated approach to support our mission and goals. The Emergency Management Committee is responsible for implementing safety measures, designing the structure of the program, setting the mission and goals, and managing implementation of the All Hazards Emergency Operations Plan. B. Scope of program The scope of the All Hazards Emergency Operations Plan of Forrest General Hospital is inclusive of all performance of personnel during a casualty drill, exercise, or actual disaster. Through assessing and measuring performance by the Department Director/Manager and Emergency Management Committee members, these findings will be integrated into the organizations hospital-wide response critique for improvement. 2. GOALS AND OBJECTIVES A. Goals From the hospital s standpoint, a disaster has been defined as any unusual occurrence involving injured persons which interrupts the hospital s routine

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-15 activity by requiring extraordinary coordination of the hospital s personnel and equipment. The goals and objectives of this plan are to: 1) Provide a workable plan of action for Forrest General Hospital in the event of a disaster, either internal or external, to the community and/or surrounding communities. 2) Be readily available to care for victims of disaster with adequate supplies, equipment, and personnel. 3) Be used as a basis for educational programs that will keep hospital personnel informed of procedures in the event of a disaster. B. Objectives 1) Each employee will be able to perform the tasks assigned to him/her at the sound of any emergency code announcement. 2) Emergency Department personnel will respond appropriately to disaster notification calls. 3) Administrative personnel or Patient Care Supervisor will execute the steps to call a disaster. 4) All employees will report to assigned work area. 5) Nursing units will evaluate census information. 6) Appropriate equipment will be delivered to the assigned area. 7) Employees will receive education in their role in the All Hazards Emergency Operations Plan. 8) The Emergency Management Committee will evaluate all emergency activations and perform an annual evaluation for improvement. C. FGH s EOP incorporates mitigations, preparedness, response, and recovery as the four phases of emergency management. They occur over time; mitigation and preparedness generally occur prior to an emergency and response and recovery occur during and after the emergency. 3. PERFORMANCE STANDARDS & EVALUATION A. Performance Standards 1) Internal and external disaster knowledge and skill of staff. 2) The level of staff participation in disaster. 3) Monitoring and inspecting activities. 4) Procedure for reporting during disasters. 5) Inspection and testing of equipment utilized in internal or external disaster. B. Evaluation 1) Monitoring The Emergency Management Committee will assign members to monitor, assess and evaluate each area responding to an emergency activation. Other hospital employees or members of the management team may be

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-16 requested to assist in this function. The evaluation will be multidisciplinary and includes licensed independent practitioners. Following each event, a critique will be conducted of the performance of FGH employees to the event. Deficiencies and opportunities for improvement will be written with deadlines for reporting improvement activities to reach the expected improvement. Improvement reports will be submitted to the Emergency Management Committee for discussion at the next monthly meeting. 2) Drills & Exercises Some aspect of the FGH All Hazards Emergency Operations Plan will be reviewed and a plan will be devised for an exercise of some aspect of the plan twice a year according to The DNV standards. Plan exercises may range from table-top discussions of procedures and processes to full-scale community exercises involving the influx of patients and integration with the community ICS structure. Emergency response exercises incorporate likely disaster scenarios that allow the hospital to evaluate its handling of communications, resources and assets, security, staff, utilities, and patients. A discussion of whether to activate the Command Center must be held with each exercise activity, and full activation of the Command Center will be expected during exercises with an influx of patients. All exercises will be evaluated, as stated above, with results reported through the Emergency Management Committee to the Environment of Care Committee. 4. PLAN INTEROPERABILITY (R011/12) A. Community-based Planning 1) Forrest General Hospital s Emergency Services Department has been evaluated and classified as a Level II Emergency Department. This level of care offers emergency services 24 hours a day with at least one physician experienced in emergency care on duty in the department and specialty consultation available within 30 minutes by members of the medical staff. 2) Referrals are made at the request of the patient and / or physician, consulting with other institutions and physicians to provide continuous medical care. Forrest General s specialists and 24-hour emergency physician coverage make this possible. 3) Forrest General Hospital is the Medical Control for the Southeast Air- Ambulance District, Baptist Life Flight and AAA Ambulance Service with Emergency Physicians as the On-Line Medical Control Office. 4) The President//CEO of the Hospital and his designee are members of the Emergency Management District Board for Forrest County, Mississippi. In the Emergency Management District Comprehensive Emergency Management Plan, Forrest General will supply medical-surgical beds for the immediate the emergency management district area. These

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-17 constitute the primary beds, and the secondary beds are those located in the outlying area hospitals, if they are not involved in the disaster situation. 5) Forrest General Hospital is a NDMS (National Disaster Medical Systems) Hospital and participates in the Operations Plan of the United States Air Force Medical Center, Keesler AFB, MS. 6) Forrest General Hospital participates in the Hattiesburg-Laurel Regional Airport (Federal Aviation) Emergency Management Plan as a member hospital with a Forrest General Hospital representative as a member of this Emergency Management Committee. 7) Forrest General Hospital is an active participant in the State Medical Response System. This Hospital Mutual Aid System (H-MAS) addresses the loan of medical personnel, pharmaceuticals, supplies, and equipment or assistance with emergent hospital evacuation, including accepting transferred patients. 8) In the event there is a disaster in a community other than Hattiesburg, the Communications Operators will respond to requests from the State Hospital Network. Pertinent information will be forwarded to the President or the Administrative person in charge. 9) Communications will be maintained by the telephone network as long as it is operative, and by radio as needed. The telephone numbers and radio frequencies which may be needed during a disaster are listed in the Telecommunications Annex. 10)Forrest General Hospital participates in the State Medical Assets & Resource Tracking Tool (SMARTT) automated system. This system allows daily input from all Mississippi hospitals tracking available resources including personnel, beds, medical equipment and pharmaceuticals in the event of a disaster. 11) Forrest General Hospital participates in the US Department of Health and Human Services HAVBED automated system. This system is a situation awareness tool to help identify health care systems stress and demand. B. Manual Layout The FGH All Hazards Emergency Operations Plan follows the layout of the National Response Plan (NRP). The Manual is divided into 5 primary sections: 1) Base Plan Section 1: The BASE Plan includes the purpose and scope of the program, goals and objectives, performance standards and evaluation, plan interoperability, responsibilities and authorities, coordinating structures (HICS, command centers), responsibility for specific guidance in disasters, implementation of plans and post-emergency management and recovery. 2) Appendices Section 2: The APPENDICES include the listing of Acronyms, Glossary, Authorities, Standards and Guidelines, Emergency Codes listing, Hazard

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-18 Vulnerability Assessment tool (HVA), Community Agency Resource List, Mutual Aid Agreements, State Medical Asset and Resource Tracking Tool, Strategic National Stockpile, Alpha Listing and Checklists. 3) Emergency Support Function Section 3: The EMERGENCY SUPPORT FUNCTION (ESF) ANNEX discusses the structures and responsibilities for coordinating incident resource support area-wide in a disaster. Forrest General Hospital is a member of The Emergency Management District (FCEMD), which is composed of response agencies, community aid groups and response related facilities within Forrest County and the City of Hattiesburg. The purpose of the FCEMD is to plan and coordinate response to emergency the various disaster-related services and agencies at the local, state and national level that may respond or interface with FGH in a local, state or federal disaster. 4) Department Annexes Section 4: The DEPARTMENTAL ANNEXES describe specific functions of various departments with a role in the emergency response of the organization. These include the following: Patient Care Services, Medical Staff, Dependent and Staff Care, Communications, Public Information, Pine Grove Behavioral Health, and a brief description of the role of each FGH department in disaster situations. These department briefs include their primary functions, as well as their role and reporting relationships during activation of the Hospital Incident Command System (HICS). 5) Incident Annexes Section 5: The INCIDENT ANNEX describes specific incidences, hazard or contingency situations that may require specialized application of the Plan. Plans are included for the following events: Bioterrorism, Bomb Threat, chemical Event and Terrorism, Civil Disturbance Plan Fire, Hazardous Materials and Decontamination, Hostage Protocol, Infant Abduction (Code PINK), Information Services (mitigation plan) and Continuity of Operations, Mass Fatality, Pandemic Flu or Infectious Disease, Radiological Release, Terrorism Explosive/Other, Trauma Mini Disaster, Utility Failure, VIP Situation, and Severe Weather Plan. 6) A diagram illustrating the structure of the FGH Manual follows this page.

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-19 FORREST GENERAL HOSPITAL EMERGENCY PLAN FORMAT BASE PLAN Concept of Operations, Roles & Responsibilities, Governance APPENDICES Glossary, Acronyms, Authorities ESF ANNEX Structures and responsibilities for coordinating ICS DEPARTMENTAL ANNEX Departmental aspects that differ or enhance (Nursing Command Ctr., Medical Staff Command, Pine Grove, etc.) INCIDENT ANNEX Biological, chemical, explosive, radiological, pandemic flu, severe weather, etc.

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-20 C. Plan Approval and Revisions (R 03/13) 1) Purpose To ensure each policy within the Forrest General Departmental Policy Manual and the Patient Care Services Policy Manual is reviewed or revised annually, and that the most recently approved copy is available for review by all FGH employees. 2) Structure a)all revisions, updates, and approvals for Forrest General Departmental and Patient Care Services Policy Manuals will be routed through the Administrative Policy Coordinator in the office of the Department of Public Safety. b) The Administrative Policy Coordinator will control: (1) Suggested annual approval dates for all policies. (2) Forms as needed for implementing policy flow. 3) Procedure (R 03/13) All copies of policies must be routed through the Administrative Policy Coordinator for approval before going online. Once a policy has been reviewed or revised and approved, the Administrative Policy Coordinator will ensure that the policy is placed online. 4) Approval Dates (R 03/13) a) Each policy will be assigned a scheduled time for approval from the Executive Committee and the Board of Trustees annually. Any changes to the suggested approval date should be routed through the Administrative Policy Coordinator. b) Approval Procedure: Once a policy has been reviewed or revised by the Department Manager and approved by the appropriate departmental committee (if required), the policy must be routed through the following steps: (1) The resource person for the policy will complete the FGH Policy Routing Form and attach to the policy hardcopy before the policy is submitted to the Board for approval. This form will follow the policy through the entire approval process. (2) After the policy has been approved, the policy is returned to the Administrative Policy Coordinator, who will communicate approval dates to the policy resource person. (3) The Emergency Management Committee Secretary will update the policy online and will maintain a hardcopy in the Department of Public Safety Administrative Office. (4) FGH Policy Routing Form, policy format guidelines, and

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-21 D. Plan Accessibility Executive/Board Approval Schedule are available on the Forrest General Intranet web page under Policies. The plan is accessible to all employees by logging on to FGH Online Intranet/ Policies/Safety/Emergency Management Plan. A hard copy of the plan is maintained by the Emergency Management Committee Secretary in the Department of Public Safety Administrative Office. 5. RESPONSIBILITIES AND AUTHORITY A. Responsibilities 1) Administration a) Overall the All Hazards Emergency Operations Plan will be under the direction of the President or Vice President, or the Patient Care Supervisor on duty at the time the disaster occurs. b) The Patient Care Supervisor, in consultation with the Emergency Department Physician is authorized to activate the All Hazards Emergency Operations Plan. Upon activation of the plan the Emergency Management Administrative Control Officer (hereafter referred to as the Incident commander) has the responsibility to coordinate all sections of the plan; to approve media releases; and to maintain the most efficient and effective patient care. c) The Incident Commander or his/her designee is responsible for notifying external agencies in the event of community emergency which is identified by the hospital. d) After determining the severity of the disaster, the Incident Commander will instruct PBX personnel to call a Code Yellow and notify key personnel and department directors/managers. They will call back personnel as needed, and the specific departmental plans will be activated. Each department will maintain a departmental plan. Upon call back, personnel will report to their respective departments and follow their specific assignments. All persons involved in the disaster will wear their time-and-attendance identification badges. 2) Medical Staff (R10/13) a) The overall medical activities in the operation of the hospital during the operation of the plan will be under the direction of the Emergency Management Medical Care Director and the Incident Commander. The Emergency Physician on duty at the time of the disaster assumes the role of the Emergency Management Medical Control Officer and the President or Administrator on call as the Incident Commander. b) The Medical Care Director will assign a team of physicians and / or Nurse Practitioner to each controlled area as needed, to include: (1) One (1) physician to the Triage Area (Emergency Entrance).

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-22 (2) Three (3) physicians to Priority I Area {Major Shock and Trauma} (Emergency Department). (3) One (1) physician to the Priority II Area {Back-up Shock and Trauma Area} (Radiology holding). (4) One (1) to Priority III Area {Minor Wounds and Burns} (Employee Health Services) 3) Staff, Employees and Personnel Each Priority Area will have a coordinator (the first nurse reporting to the area will become the coordinator of the area). Identification vest (to be distributed by Emergency Department personnel) are to be worn by each coordinator. B. Responsibilities by Departments (see Section 4: Dept. Annex) C. Authorities (see Section 2: APPENDICES) The Forrest General All Hazards Emergency Operations Plan and all plans related to the preparation for, response to and recovery from a disaster event are submitted to the Emergency Management Committee for approval, and then sent to the Environment of Care Committee. On approval of this committee, recommendations for adoption are submitted to the Administration and final approval by the Board of Trustees of the hospital. All local, state and federal laws, guidelines and authorities are considered and addressed, where appropriate, in the writing and review of the All Hazards Emergency Operations Plan. 6. COORDINATING STRUCTURES A. HICS Command Structure The Hospital Incident Command System (HICS) divides authority for management and leadership of a disaster activation into operational sections and units. The command structure is directed by the Incident Commander. This role should be filled by the most senior and best qualified incident leader on duty at the moment. As additional management staff are being identified and notified of an activation, the Incident Commander should begin organizing the Command Staff and activating the Command Center. The Command Staff consists of 5 roles, serving as direct advisors to the Incident Commander: Safety Officer, Public Information Officer, Liaison Officer, Medical Staff Director and Medical Specialist. The Command Staff are assisted in leadership during the activation by the Section Chiefs over Operations, Logistics, Finance and Planning. Each Section Chief should activate sub-roles as necessary to provide adequate and timely management to responders and the community.

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-23 B. Command Integration and Interoperability 1) Community Agencies / Hospital Interface (see ESF Annex) The value of an integrated command system (ICS) is to allow all responding agencies in the local and surrounding areas to operate under the same command structure. FGH will follow the prescribed local ICS and integrate fully with community agencies in activation for a disaster event or during exercises. 2) FGH Command Centers a) Command Center Locations FGH may activate a number of command centers, depending on the type, extent and nature of the event. The primary Incident Command Center will be activated in the FGH Board Room. Patient Care Services may also activate a separate command center (for the purpose of management of clinical staff and evacuation/transfer of patients) in the Patient Care Services Department Conference Room. In an event isolated to Pine Grove, or in a community-wide event, Pine Grove Behavioral Health may also activate a command center in their administrative building. To facilitate communication and coordination, a liaison from Patient Care Services and Pine Grove will be present in the FGH Command Center at all times. The FGH medical staff will report to a designated area Medical Staff Command Center to pick up in-house radios and receive their assignment during activation periods. b) Activation of Command Centers (1) The primary FGH Command Center will be located in the FGH Board Room. It will be manned by personnel assigned by the administrator on call. (2) Complete Criteria Checklist for Activating FGH Incident Command Center. (3) Direct the Communications Operators to advise all personnel on duty that the All Hazards Emergency Operations Plan is in effect (by paging CODE YELLOW ). (4) Check to be sure that? (Emergency Physician on duty at time of the disaster) has established a Medical Command Post in the Emergency Department. A secretary or unit secretary will be assigned to this area to give pre-established assignments to physicians reporting to this area. (5) The Command Center will: (a) Verify that all personnel listed on the key personnel directory

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-24 have been notified by the Communications operators. (b) Ensure a Triage Area has been set up in the Emergency Entrance and is staffed. (c) Verify that PCS will assign the appropriate person to oversee patient care disaster areas and notify? office of any needs. (d) Verify that Public Safety has notified appropriate emergency response agencies for traffic and crowd control assistance. (e)ensure that the News Media Office has been set up in the Oak Room (extension 81764) and the Marketing and Communications designee is directing news media and communications. (f) Check with Human Resources to verify that a temporary child-care center has been established for children of employees called back or other appropriate reasons deemed necessary by Administration. This child-care center will be located in the cafeteria meeting rooms for employees who find it necessary to bring children with them. Personnel pool employees may assist with this area. 3) The Incident Commander, or his designee, will verify bed availability with area hospitals by accessing the SMART system. 4) All non-clinical department supervisors or designees should notify the nonclinical labor pool of available staff and skill level via e-mail. 5) Laboratory personnel will provide available blood information to the PCS Incident Command Center. C. Department Directors / Managers are to stay in their departments while the plan is in effect, unless departmental plan specifies otherwise or unless they are directed by the?. 1) Facility transportation will be provided to be used for transporting minor wounded to other facilities as needed. 2) Administrator on call or the Patient Care Supervisor will make the decision to activate the internal HICS operation. 3) The form, Criteria Checklist for Activating FGH Incident Command Center (page ) may be used to assist in decision-making to activate a Command Center. 4) The Marketing and Communications Director will report to the Command Center as the Public Information Officer. 7. SPECIFIC GUIDANCE IN DISASTERS A. All Hazards Emergency Operations Plan

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-25 1) The Department of Emergency Service is an integral part of the disaster plan for the hospital. In addition, the All Hazards Emergency Operations Plan of Forrest General Hospital is integrated with a broader, communitywide disaster plan for larger scale disasters. All personnel must be familiar with the disaster plan, a copy of which will be available. The Hospital will participate actively in community and area-wide planning for disasters and at least twice yearly in mock-disaster practice exercises. The Department of Emergency Services will participate in these exercises. 2) In the event of a major disaster, the President or his/her designee directs activation of the All Hazards Emergency Operations Plan. 3) Upon notification of a potential disaster (CODE YELLOW): a) Notify Patient Care Supervisor. b) Notify the emergency physician for their evaluation of the severity of the disaster. c) Call the Patient Care Supervisor on duty, Patient Care Manager, or Emergency Department Patient Care Coordinator and inform of the situation. d) Registration will immediately locate Disaster ID Packs and Coordinator ID Bands and bring them to the desk. e) Notify physician on" Specialty Call" for that day at the discretion of the emergency physician. f) Call back three RNs immediately. g) Assess patients in the Department of Emergency Services (1) Assign all patients currently in the Department of Emergency Services with admission orders up to the patient care unit as soon as possible. (2) Have technicians take wheelchairs and available stretchers to the hallway at the West end of the red zone area of the Emergency Department. Then technicians will return to their assigned areas. h) In the All Hazards Emergency Operations Plan, the Department of Emergency Services is the area for major trauma, major shock, major burns, and major lacerations. Prepare to set up for these conditions immediately. Material Supply Services/Cart Logistics will send supply carts as soon as the CODE YELLOW is in effect. 4) Department of Emergency Services personnel set up the triage area in the emergency entrance and waiting areas. B. Preparedness & Planning. 1) Hospital Leaders and Medical Staff Hospital leadership and medical staff participate in the emergency

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-26 planning activities including developing and updating operational plans. Medical staff and leaders are active members of the Emergency Management Committee 2) Emergency Management Committee The Emergency Management Committee is composed of representatives from a variety of the hospital departments, appointed by Administration on an annual appointment, but may be extended at any time. The committee oversees the health system s preparedness to emergencies or situations that tax its resources. The Emergency Management Committee reports through the Environment of Care Committee to the Administrative Team. Forrest General Hospital is a member of The Emergency Management District (TEMD), which is composed of response agencies, community aid groups and facilities within Forrest County and the City of Hattiesburg. The purpose of the TEMD is to plan and coordinate response to emergency events. Forrest General Hospital bases emergency and disaster planning on a Hazards Vulnerability Assessment (HVA) used to evaluate the organization s areas of risk and vulnerability, and identify focus areas for preparedness. The HVA will be completed by a subcommittee of the EM Committee annually. Findings are compared with the FCEMD HVA for identification of missed risks or reconsideration of planning goals for FGH. 3) Review / Revision The entire All Hazards Emergency Operations Plan is reviewed annually by the Emergency Management Committee, with revisions made as needed. The Plan may be reviewed as a whole, or incrementally in sections. All revisions are indicated by the code RM/YY,(i.e., R10/06 for Revised October 06) and the process of administrative review is fully documented at the end of each plan type. Revisions are approved by the Emergency Management Committee and forwarded to the governing board for approval annually. 4)Drills & Exercises Preparedness drills and exercises are conducted in accordance to the standards established by The DNV. The Emergency Management Committee sets the schedule of exercises and drills twice a year according to DNV standards, and evaluates the drill or activity while prioritizing improvement activities. Additional drills are conducted based on the recommendations of the Emergency Management Committee. During drills or exercises, all operations will continue unless otherwise directed by the Incident Commander. Drills will be conducted as appropriate. Emergency response exercises will incorporate likely disaster scenarios that allows Forrest General to evaluate its handling of communications, resources and assets, safety and security, staff roles and responsibilities, utilities, and patient clinical and support activities. The Hospital designates an individual(s) to monitor performance and

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-27 document opportunities for improvement. This individual is knowledgeable in the goals and expectations of the exercise. Exercises are critiqued to identify deficiencies and opportunities for improvement based upon all monitoring activities and observation during the exercise. Completed exercises are critiqued through a debriefing, which is multidisciplinary and includes administration, clinical (including physicians), and support staff. The All Hazards Emergency Operations Plan is modified in response to critiques of exercises. 5) Hazards Vulnerability Assessment Forrest General Hospital bases emergency and disaster planning on a Hazards Vulnerability Assessment (HVA) used to evaluate the organization s areas of risk and vulnerability, and identify focus areas for preparedness. Risks and vulnerabilities are actively assessed on an ongoing basis during debriefings of exercises and actual events. As mitigation issues are identified, steps are taken to reduce the risk. The HVA will be conducted be a subcommittee of the EM Committee annually. Findings are presented to the Forrest County TEMD for identification of missed risks or reconsideration of planning goals for FGH. 6)Evacuation and Patient Transfers (see Section 4: Annex A: Patient Services) 7) Vehicular Access to Emergency Services All patients arriving in the Emergency Services Department shall be asked by the triage personnel where they are parked. If they respond that they are parked in one of the spaces immediately outside or adjacent to the Emergency Entrance, and if they do not require handicapped parking, then the driver will be asked to park across the street in the Emergency Services parking lot. The Public Safety Officer assigned to the Emergency Services Department will monitor the ambulance entrance parking area and will direct operators to the appropriate parking areas. 8) Elevators Operations in Disasters (a) Elevator operations will continue throughout the disaster. (b) The Engineering Department will maintain the availability of the elevator system. (c) Casualties, wheelchair patients, stretchers, and essential supplies will have priority on elevators during the time the All Hazards Emergency Operations Plan is in effect. 9) Helicopter Landing and Departing In accordance with Federal Aviation Administration requirements, Public Safety Officers will be notified via radio when the helicopter is departing or landing. Prior to and after flight missions officers will maintain security. 10) Access Control

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-28 The Department of Public Safety will provide two levels of Access Control for Forrest General Hospital: Controlled Access and Lockdown. Controlled Access provides for restricted entrance and exit from the building. Usually one entrance, manned by a Public Safety Officer, is provided for non-emergency Department patients. The ED will remain open, though security will be present for entrance control. Lockdown is a complete closure of the facility to all personnel, employees and visitors. Visitors will be asked to leave immediately. All entrances will be locked. No one will enter or leave the facility during a Lockdown situation. a) Controlled Access The Department of Public Safety, in conjunction with Administration, will determine when controlled access to the hospital is warranted. Controlled access plan implementation will require that all entrances to the hospital be locked except the front door and the Emergency Department. Additional entrances will be opened and directed by the Incident Commander. Public Safety Officers will lock all entrances except the designated control access points. Public Safety Officers will provide security at entrances, assist with the admit visitors, and issue arm bands. Temporary signs will be placed at the locked entrances giving notice of the Controlled Access status and instructions for accessing controlled access entrances. b) Lockdown The Department of Public Safety, in conjunction with the Administration, will determine if total lockdown of the hospital is warranted. Once the decision to lockdown is made, Public Safety Officers will lock all entrances to the facility. Temporary signs will be placed at each entrance giving notice of the lockdown. No one will be allowed to exit or enter the facility during lockdown unless approved by the Public Safety Officers, in conjunction with the Administration. 11) Sheltering Policy & Dependent Care (SEE Section 4: DEPT Annex C) a) Sheltering Policy b) Dependent Care Program 12) Alternate Care Sites (see also 11: Priority Areas, page 33 ) C. Management of Resources and Assets. (R 10/11) 1) The hospital has an automated inventory system that tracks in-stock supplies and reorders as items are used. This system maintains a par level of medical and non-medical supplies available for five days. The SMARTT system and vendor emergency supply agreements will be utilized in order to maintain adequate supply levels. 2) Food and Nutrition has a four day supply of food and beverages. Contracts are in place to ensure delivery and restocking as needed. 3) Pharmaceuticals have an automated inventory system, McKesson, which

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-29 tracks medications and reorders as needed. The Center of Disease Control stores a disaster chempack in the Pharmacy Department for regional deployment as necessary. The SMARTT system and vendor emergency supply agreements will be utilized in order to maintain adequate supply levels. 4) In addition to stored bottled water, the hospital is equipped with a deep water well, a 1,100 gallon per minute pump, and a 750,000 gallon water storage tank. The system is connected to the municipal water department and is equipped with a valve system to seize the water supply, if needed. 5)? 6) On campus are four 12,000 gallon tanks for the 7.5 mega watt generator plant. In addition, the hospital is equipped with four in-house generators located in the basement; two 1,000 KW generators and two 500 KW generators with a total fuel tank capacity of 3,000 each. Par levels are typically kept at 1,000 gallons in each tank, depending upon the situation. 7) A subcommittee of the Emergency Management Committee meets annually to conduct a review of FGH s inventory process. The findings are reported to the EM Committee and documented in the committee minutes. 8) In the event there is a disruption in the normal water supply, or the back up water supply (water well and 750,000 gallon water storage tank), patient sanitation will be red-bagged and disposed of as biohazard waste. Another method is the use of cat litter in red bags. If using this method, the red bags and cat litter will be placed in toilets. When deemed necessary by infection control, the red bags will be removed from the toilets and disposed of as a biohazard. 8. IMPLEMENTATION OF PLANS A. NIMS, Introduction to Implementation 1) National Incident Management System (NIMS) Homeland Security Presidential Directive 8 (HSPD-8) National Preparedness, called for a domestic all-hazards preparedness goal that established measurable readiness priorities and targets, standards for preparedness assessments and strategies and a system for assessing the National s overall level of preparedness. Overarching priorities were to a) Implement NIMS and the National Response Plan, b) Expand regional collaboration, and c) Implement the National Infra-structure Protection Plan. The NIMS program was first published March 1, 2004, institutionalizing the Incident Command System (ICS) and control structures across States and local and tribal jurisdictions. This was followed in April 2005 with a Target Capabilities List (v 1.1) describing the capabilities needed to perform critical homeland security tasks. These describe critical tasks that must be performed during a major event to prevent occurrence, reduce loss of life or serious

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-30 injuries, mitigate significant property damage, or are essential to the success of a homeland security mission. There are 36 specific capabilities and levels of capability that Federal, State, local and tribal entities are expected to develop and maintain. These include fatality management, communications, planning, medical surge, mass prophylaxis, triage, pre-hospital treatment, among others. The NIMS Integration Center (NIC), with DHHS, released NIMS guidance for hospitals on September 12, 2006. Designed to assist healthcare organizations with implementation of NIMS, seventeen (17) Implementation Activities are specified, and Emergency Management programs should reflect or include these 17 items (also known as Essential Elements ). 2) FGH NIMS Compliant The Administration of FGH is committed to achieving NIMS compliance. Following the release of NIMS Implementation Activities for Hospitals and Healthcare Systems by the US Department of Homeland Security 09/12/06, all healthcare organizations are expected to comply with a series of activities designed to assist hospital and healthcare systems with their implementation of NIMS, further enhancing the efficiency and effectiveness of their response and recovery role. 3)NIMS Essential Elements and FGH Planning The Essential Standards List represents a set of the most significant national standards for NIMS. The 17 NIMS Implementation Activities for Hospital and Healthcare Systems are as follows: a) Adoption of NIMS b) Incident Command System (ICS) c) Multi-agency Coordination Systems (MACS) d) Public Information Systems (PIS) e) NIMS Implementation Tracking f) Preparedness Funding g) Revise and Update Plans h) Mutual-Aid Agreements i) ICS 700 NIMS j) ICS 800-A NRP k) ICS 300 and 400 l) ICS 100 and 200 m) Training and Exercises n) All-Hazards Exercise Program o) Corrective Actions

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-31 p) Response Inventory q) Resource Acquisition r) Standard and Consistent Terminology 4) A template outlining expectations of hospitals and healthcare systems in each of these 18 Elements, as well as measurements of compliance by Forrest General Hospital are included on page at the end of this Section. B. HICS - Roles in All Hazards Emergency Operations Plan 1) HICS Response Personnel The Management Team and Patient Care Supervisors will form the most likely first response group for activation of the command center and implementation of the HICS program in disaster situations. The Incident Command Center will be activated at any time the most senior clinical leader feels the need is warranted even if this action is precautionary. The initial Incident Command Center staff may be selected from those on duty at the time, as additional management staff is notified for call-back. The Incident Command Center may be configured with activation of sections and roles as the event dictates. All positions need not be activated for a comprehensive response. The Incident Commander, working through and with administrative input has the authority to stand down the incident command center, but only when all patient activity as returned to normal. The Incident Command Center will remain staffed and operational as long as the Patient Care Incident Command Center is activated. 2) Employee Assignments C. Volunteers Most hospital employees will report to their departments for assignment during disaster events. Employees assigned to work the Incident Command Center will be notified by their supervisor of this tasking. Employees may be asked to work alternate schedules and in locations they may not have been previously assigned. Under no circumstances will non-clinical personnel be allowed to provide direct patient care; however, they may be requested to fill roles to assist clinical staff in the performance of their duties. All personnel are subject to assignment to non traditional roles in disaster situations. Volunteers are a crucial resource in the smooth operation of FGH during a disaster activation. Volunteers will be coordinated by the Human Resources Department, and will report to the site designated for them for assignments. (see Volunteers in Preparedness Registry (VIPR) in Appendices Section 2, page 2-13) D. Job Action Sheets HICS Job Action Sheets provide a general overview of the tasks to be performed in each section and position within the incident command chain.

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-32 These JAS s have been personalized for the most likely activations at FGH; however, the incident will dictate flexibility on the part of managers and the ability to alter their response as required to address issues that arise as a cohesive team. JAS s will be reviewed and revised as needed. E. Orientation and Education 1) Training for employee responsibilities during a disaster begins on the first day of orientation. New employees has 3 days to complete the required computer based training. Each employee is trained on his or her responsibilities during a disaster situation. On the job training will continue until the employee is able to function independently. Upon activation of the All Hazards Emergency Operations Plan, all employees will return to their designated unit and fulfill their roles and responsibilities. 2) The orientation and education plan consists of the following: a) Specific roles and responsibilities of personnel in the Emergency Department. b) The specific roles and responsibilities of personnel functioning within the specific disaster areas during a disaster. c) Specific roles and responsibilities of other personnel during an external disaster. d) Activation of the All Hazards Emergency Operations Plan, location and distribution of equipment and supplies for use in a disaster e) The plan of each person s specific departmental All Hazards Emergency Operations Plan. f) Communication during disaster. g) ICS 100 and ICS 200 h) Paraslyde patient evacuation system training 3) The pre-established indicators are assessed and measured by the disaster observers and the Emergency Management Committee each time a drill occurs. The pre-established criteria include evaluation of each individual area s performance. F. Notification of a Disaster In House 1) Patient Care Supervisor, in consultation with the Emergency Department Physician, is authorized to activate the All Hazards Emergency Operations Plan. The Emergency Department or person receiving the information will notify Administration or the senior person in charge of the hospital. 2) Emergency Department personnel receiving the notification of a disaster call will attempt to verify the call by identifying the source of the call and attempt to obtain the following information: a) Type of disaster b) Location of disaster

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-33 c) Number of casualties d) Possibility of hazardous materials contaminated patients e) Extent and nature of injuries f) Expected time of arrival g) In the event another department receives notification of a disaster situation, they will notify the Emergency Department, Administrator on call, and the Patient Care Supervisor immediately. 3) Administrator on call will call a CODE 11, if time allows and deemed necessary. 4) Patient Care Supervisor will notify the Communications Operator to page CODE YELLOW over the public address system and direct activation of the All Hazards Emergency Operations Plan. 5) All key personnel in the hospital, after proper notification, will report to the physician s dining area for further instructions. An Administrative Secretary, if at work, will check in all key personnel as they report to this area. The President s office and Chief s offices may be used for call back of personnel as needed; and the switchboard may be directed by the Incident Commander to execute the call back of key personnel list via group paging and electronic bulletin board instructions for an immediate response situation. 9. INTERNAL CODES A full description of the internal disaster codes for Forrest General Hospital is included in Section II: APPENDICES 10. MEDICAL CONTROL AND MEDICAL STAFF ASSIGNMENTS All medical activities during the operations of the Emergency Management Control Plan will be under the direction of the Medical Control Officer. A. Medical Staff Director Emergency Physician on duty at time of disaster or his designee - He/she will be responsible for assignments of private physicians to the Emergency Department and additional triage and treatment areas. Assignments will be made as appropriate for the number and type of patients in each area. B. Medical Control Will be set up either inside or outside of the Emergency Department, as the situation dictates. 11. PRIORITY AREAS (R 10/13) Priority Areas I, II and III, will have an assigned physician/nurse practitioner who will stay in the area. These Priority Areas will have a clerical employee assigned by Patient Care Services. Each Priority Area will maintain appropriate documentation. RNs will be assigned to Priority Areas by Patient Care Services and staffed according to volume and acuity of patients. Physical Therapy may be used to receive patient overflow from the Emergency Department, Radiology Holding and Employee Health in the event a CODE

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-34 YELLOW is called. Staffing assignments will be made through Patient Care Services. Vulnerable populations are patients who are pediatric, geriatric, disabled or have serious chronic conditions or addictions. As these patients are identified in the triage process, they will be linked with medical Social Services and needed hospital services. For those services Forrest General Hospital cannot provide, Medical Social Services personnel will assist the patient by linking them with healthcare or social service agencies that can provide the assistance the patient requires. A. Triage Area The Triage Area will be established immediately outside the Emergency Department (ED) in the covered area or at the site of the disaster. All patients presenting to the ED will be triaged in that area. In case of an internal disaster, regular triage will be maintained in the ED. Staffing 1) Chief Triage Medical Officer -- First available Emergency Physician. 2) Chief Triage Nurse -- An emergency nurse qualified to triage in the ED. 3) Chief Registration Clerk -- Registrar will remain at triage and document all patients being brought into the emergency areas during the disaster situation. 4) Triage Registrars: Registration personnel will follow the patient until all information concerning the patient is obtained. Registrar will then return to Triage Area. 5) Patient Advocates will be assigned to each patient brought into the emergency area. (See Roles) 6) ED Triage Clerk - assigned to regular triage registration desk. Will input name and birth date on all patients into clinical documentation system and obtain chart, armband, and stickers. Patients with no known name or birth date will follow regular ED procedure for unidentified patients. B. Priority I Area -- Emergency Department Critically injured patients needing immediate treatment. 1) Telephone Number: 288-2100 2) Staffing a) ED Physician b) ED Patient Care Coordinator (PCC) c) Unit Secretary d) ED Nursing Staff e) Respiratory Therapy Staff f) Private physicians as needed

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-35 g) Other personnel as needed, as determined by PCC and ED Physician h) Responsible for the treatment of all patients assigned to the Priority I Area by the Triage Area. Patients in the ED at the time of notification of the disaster situation will be assessed to determine if patient is ready for discharge or admission to inpatient status. The ED physician can determine the need to send ED patients to other priority areas as beds are needed. All patients must have a medical screening exam as defined in the ED policy before discharge. C. Priority II Area -- Radiology Holding Non-critical injuries (probably requiring hospitalization). 1) Area Coordinator - A Nurse from the Emergency Department. 2) Staffing a) Physician - A Priority II physician will be appointed by the? and will report to Priority II to oversee medical direction of the Priority II Area. A vest will be distributed by the Medical Control Officer to the designated physician. The physician will assess the disaster victims for appropriate care and disposition and direct concerns to Priority Area Coordinator. b) Nurses (1) Priority Area II Nurse Coordinator (a) Don vest (b) Reports directly to Area II to assess needs and set unit up for disaster (c) Optimally, will not become involved in direct patient care but remain available at nurse s station as able for overall supervision and coordination of Priority II (d) Assign and supervise functions of staff reporting to Area II (e) Pull and / or call for needed supplies (f) Direct communication to Patient Care Supervisor and the Command Center (2) Other RNs (a) Oversee patient care (b) Obtain equipment and set up area for treatment (c) Communicate needs to Area Coordinator c) Clerical Support (1) Will report to Area Coordinator (2) Prepare area to see patients

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-36 (3) Assist as needed in initiating orders (4) Assist Coordinator in communicating patient information to Patient Care Services D. Priority III Area: Employee Health Services (R 10/11) Non-critical injuries such as minor burns, lacerations, fractures, eye injuries, etc. that will probably be discharged. 1) Area Coordinator During operating hours, a designated Emergency Department Nurse will be the area coordinator. After operating hours, first RN to arrive. Other RNs will be sent from Patient Care Services. Priority III Coordinator supervises assembling of supplies. Overflow patients may be placed in adjacent rooms, and/or using beds as bench seating. 2) Staffing a) Physician - A Priority III physician and\or Nurse Practitioner will be appointed by the Medical Control Officer and will report to Priority III to oversee medical direction of the Priority III area. A vest will be distributed by the Medical Control Officer designate as physician. The physician and\or Nurse Practitioner will assess the disaster victims for appropriate care and disposition and direct concerns to Priority Area Coordinator. The Priority III Physician and\or Nurse Practitioner will collaborate with the Nurse Coordinator in deciding capacity of Priority Area and when walking wounded should be transported by hospital transportation to selected facility. b) Priority Area III Coordinator: Responding RN (1) Don vest (2) Will report directly to Priority Area III to assess needs and set unit up for disaster (3) Optimally, will not be involved in direct patient care but this nurse will be located at the Radiology Holding doorway triaging walking wounded (4) Collaborate with Physician and\or Nurse Practitioner in deciding area capacity and when walking wounded should be diverted to other areas or discharged. Report decisions to Patient Care Services (5) Assign and supervise functions of staff reporting to Priority Area III (6) Supervise assembling of supplies from disaster cart. Pull and/or call for needed supplies (7)Direct communication to Patient Care Supervisor, and Administrative Command Center

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-37 (8) Material Supply will deliver disaster cart to the area. c) Nurses (1) Minimum of 1 RN will oversee patient care (2) Obtain equipment and set up area for treatment (3) Communicate needs to Area Coordinator d) Clerical Support (1) Reports to Area Coordinator (2) Prepare area to receive patients (3) Assist as needed in initiating orders (4) Assist coordinator in communicating location of patient s information to PCS e) Radiology Personnel (1) Assist in the Priority III Area, facilitating use of supplies (2) Assist with treatment of Priority III patients (3) Maintain inventory of disaster supplies in Priority III Area 3) Morgue(Morgue Area) 12. CALL BACKS A. Personnel a) The Public Safety Department will be responsible for the Morgue operation b) Morgue Utilization Form will accompany all bodies c) The Command Center and Patient Care Services will be kept informed of census of the morgue. 1) Upon receiving direction from person in charge, each Department Director or Manager will initiate a call back of personnel as needed according to their plan. Specific departmental plans will be activated. Upon call back, personnel will report to their respective departments and follow their specific assignments. 2) The Emergency Department or its designee will notify all physicians on call (for the day) and other physicians as directed by the Medical Control Officer (Emergency Physician on duty at time of disaster). The Medical Control Officer will make assignments of physicians until Medical Staff Command Center is activated 3) Available bed screens on MISYS will be captured by Room Assignment and faxed to Patient Care Services (fax 1075) and Administration Headquarters (fax 2148). 4) Regency will provide available bed list to Patient Care Service.

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-38 5) Department Directors/Managers or designees are responsible for maintaining and activating appropriate call list for their department personnel. 6) All staffing needs will be based on the severity of the disaster. Under certain circumstances it will be necessary to adjust from a normal eighthour working day to a 12 or 16 hour schedule. 7) Inquiries by staff responding to a callback initiative will be referred to their departments for specific instructions unless directions are available in Physician Dining Area. B. Medical Staff The Chief Medical Officer (CMO), or his/her designee, will determine the need to call back additional medical staff during a disaster. 13. POST EMERGENCY MANAGEMENT AND RECOVERY A. Stand-Down Command Centers 1) An All Clear will be call by the Administrator in charge after consultation with the Medical Control Officer and all outside agencies involved in the emergency situation. 2) A post emergency management census will be run. All areas will be surveyed and closed and returned to their normal function by the personnel in charge of that area. B. Assessment, Post-Event Each disaster event will be critiqued for appropriateness of the response by FGH staff. These assessments may be completed on various forms, but the summary of the assessment will be submitted to the Emergency Management Committee for review at the next earliest meeting. Opportunities for Improvement in response will be identified and an action plan approved to address and correct these issues. Progress will be reported at each Emergency Management Committee meeting until the situation is rectified. C. Recovery (Return to Normal) The recovery phase begins when response ends. Recovery can be either short or long term and addresses the goal of the successful return to normal operations (or a newly defined normal for the facility or community). Recovery planning will be led by Administration and a recovery plan will be written, with the assistance of the Emergency Management Committee, to ensure all areas of operation are addressed. This recovery plan will include tasks, timelines and a reporting mechanism for successful completion. The Recovery Plan will be presented and discussed at the Emergency Management Committee following the event, and progress reports will be made until full recovery is achieved.

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-39 TABLE 1. Measurements for NIMS Compliance and Proposed Measures for FGH NIMS Elements Explanation Measures for FGH 1. Adoption of NIMS 2. Incident Command System (ICS) 3. Multiagency Coordination System 4. Public Information System Adopt NIMS at the organizational level for all appropriate departments and business units; promote and encourage NIMS adoption by partners and suppliers Manage all emergency incidents, exercises and preplanned events following ICS organizational structures, doctrine, and procedures, as defined in NIMS. Develops and uses integrated multiagency coordination system to coordinate and support emergency incident and event management. Develop and coordinate connectivity between Hospital Command Center, EOC s, 911 centers, and Incident Command Posts. Implements processes and/or plans to communicate timely accurate information through a Joint Information System (JIS) and Joint Information Center (JIC). The 18 elements are addressed in the FGH emergency management program documentation Implement an ICS (HICS) that allows for the safe and effective patient care and continuity of operations. HICS should be included in the Emergency Operations Plan (EOP), which identifies an Incident Commander, and appropriate personnel to meet ICS areas for effective Incident Command. Training and exercises are conducted to review the structure and ICS responsibilities of hospital personnel. FGH participates in collaborative planning, resulting in exercises and training conducted among the agencies to test and validate facilities, equipment, personnel, procedures and integrated communications. FGH s EOP demonstrates the management and coordination connection between these command centers and agencies. FGH s EOP explains the management and coordination of public information with healthcare partners and jurisdictional authorities (pubic health, EMS, emergency management and others). FGH has at least one PIO responsible for media and public information pertaining to critical events involving the hospital. PIO establishes working relationships, prior to an incident, with local media and primary community organizations.

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-40 NIMS Elements Explanation Measures for FGH 5. NIMS Implementation Tracking 6. Preparedness Funding 7. Revise and update plans Hospitals will track NIMS implementation annually as part of the organization s All Hazards Emergency Operations Plan Develop and implement a system to coordinate appropriate hospital preparedness funding to employ NIMS across the organization. Hospitals should also proactively seek funding to support preparedness and interoperability training with local and regional partners. Assistance should be coordinated through the state Hospital Association and Emergency Management Authority. EOP s and SOPs are revised and updated to incorporate NIMS components, principles and policies, including planning, training, response, exercises, equipment, evaluation, and corrective actions. NIMS organizational adoption, command and management, preparedness planning, training, exercises, resource management, and communication and information management activities will be tracked annually and compared year to year with a goal of improving overall emergency management capability. FGH s EM program documents information on local, state, and federal preparedness grants that have been received and deliverables to be achieved. Documentation demonstrates that preparedness grants received by the organization meet any regional, state or local funding commitments. FGH s plans describe how personnel, equipment, and other resources will support incident management activities. FGH will establish the necessary policies and procedures to achieve preparedness and respond to and recover from an incident. Once updated, plans will be exercised and reviewed to determine and measure functional capability. Plan reviews will be conducted annually and/or after every event or incident to identify future updates that may be needed. 8. Mutual-Aid Agreements (MAA) Participate in and promote interagency mutual-aid agreements, including with public and private sector and/or nongovernmental organizations FGH will establish mutual-aid agreements with neighboring hospitals and/or healthcare systems, public health departments, hazardous materials response teams, local fire department, local law enforcement, area pharmacies, and/or medical supply vendors. All MAA s will be shared with local EMA prior to an incident occurring.

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-41 NIMS Elements Explanation Measures for FGH 9. IS-700 NIMS Personnel that would have a direct role in emergency preparedness, incident management, and/or emergency response during an incident, and those designated to fulfill ICS roles, must complete ICS 100 (Introduction to ICS) or equivalent course. 10. ICS-800.A National Response Plan: An Introduction Hospital personnel whose primary responsibility is emergency management, including middle management (MD s, dept managers, unit leaders, charge nurses, any staff with emergency operations role) must complete ICS 200: ICS for Single Resources and Initial Action Incidents Personnel whose primary responsibility is emergency management within a hospital must complete IS-800. The hospital training program tracks completion of this course. 11. ICS-300 & 400 Personnel whose primary responsibility is emergency management within a hospital must complete ICS 300 and ICS 400. These courses focus on preparing for an expanding event requiring interaction with other agencies. The hospital tracks completing of this course. FGH will include IS-700 in required yearly safety or as part of employee evaluations to achieve training for all identified hospital personnel. FGH will maintain one overall record of completion for employees as well as documentation in the employee s personnel file. FGH will include IS-800 in required yearly safety or as part of employee evaluations to achieve training for hospital employees whose primary responsibility is emergency management within the hospital. FGH will maintain one overall record of documentation in the employee s file. FGH will include IS 300 and ICS 400 in required yearly safety or as part of employee evaluations to achieve training for hospital employees whose primary responsibility is emergency management within the hospital. FGH will maintain one overall record of documentation in the employee s file.

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-42 NIMS Elements Explanation Measures for FGH 12. ICS 100 and 200 Personnel that would have a direct role in emergency preparedness, incident management, and/or emergency response during an incident, and those designated to fulfill ICS roles, must complete ICS 100 (Introduction to ICS) or equivalent course. Hospital personnel whose primary responsibility is emergency management, including middle management (MD s, dept managers, unit leaders, charge nurses, any staff with emergency operations role) must complete ICS 200: ICS for Single Resources and Initial Action Incidents FGH s education department tracks completion of the ICS-100 and ICS-200 or equivalent courses by personnel who will have a primary responsibility as part of the emergency management program. 13. Training and Exercises 14. All-Hazard Exercise Program 15. Corrective Actions Incorporate NIMS/HICS into internal and external local, regional, and state emergency management training and exercises. Participate in an all-hazard exercise program based on NIMS that involves responders from multiple disciplines, agencies and organizations. Hospitals will incorporate corrective actions into preparedness and response plans and procedures. FGH will include NIMS and HICS policies and practices into internal and external training and exercises. During trainings, plans will be reviewed to ensure hospital staff competency and proper execution of roles and responsibilities during an event. FGH s emergency management program training and exercise documentation reflects the hospitals participation in exercises with various external entities. FGH will participate in local, regional, and/or state multidiscipline and multiagency exercises twice per year, addressing internal and external communication, receiving, triage, treatment, transfer of mass casualties, progression of casualties through the hospital system, resource management, security procedures, specialty lab testing, and/or site/facility safety. A corrective action report will be prepared addressing a corrective action process following participation in a drill or exercise, or following an actual event.

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-43 NIMS Elements Explanation Measures for FGH 16. Resource Inventory 17. Resource Acquisition 18.Standard and Consistent Terminology Maintain an inventory of organizational response assets. Establish common equipment, communications, and data interoperability resources with other local hospitals, EMS, public health, and emergency management that will be used during incident response. Apply standardized and consistent terminology, including the establishment of plain English communication standards across the public safety sector. FGH will maintain a resource inventory by determining supplies and equipment that will be used in excess during an incident response; and will order, and stock onsite or elsewhere prior to an event. A record of inventory will be maintained or supplies or response assets maintained. MOU s or MOA s will be developed to expedite receipt of items whose usage would exceed par levels in a large scale incident or for items in which expiration would be an issue. FGH s EM documentation will include emphasis on the interoperability of response equipment, communications, and data systems with external entities. FGH s EM program documentation reflects an emphasis on the use of plain English by staff during emergencies. Plain language will be addressed in plans as well as written into training and tested during drills and exercises.

ALL HAZARDS EMERGENCY OPERATIONS PLAN 1-44 CRITERIA CHECKLIST FOR ACTIVATING FORREST GENERAL HOSPITAL INCIDENT COMMAND CENTER If two or more of the following questions are answered Yes, strongly consider activating the Incident Command Center. Is there an immediate need to coordinate/change care standards and protocols? Is system wide decision making needed to assist in overseeing a disaster-related event? Is system wide media coverage coordination needed to assist in reporting a disasterrelated event? Is there a patient surge large enough for mass-casualty related healthcare? Is opening alternate care areas necessary? Are patients presenting at the Emergency Department who need to decontaminate? Is the hospital going to either controlled access or lock-down? Is there a need to establish alternate care sites? TOTAL YES N O If one or more of the following questions are marked yes, activate the Forrest General Hospital Incident Command Center. (to appropriate level) Has a terrorist event occurred within a 50 mile radius of Forrest General? Has a mass casualty event occurred within a 50 mile radius of Forrest General? Has activation of the FGH Command Center been requested by an external agency? (The Emergency Management District, Health Dept., etc.) Has there been a loss of utilities or systems? (electricity, water, computers, telephones, etc.) Is there a major weather event or warning? (Hurricane, tornado, flood, ice storm) Is there a need to deploy additional staff or stage relief staff on sight? Is there a need for emergency supply or stockpile of supplies? Is there a need to coordinate/consolidate/interpret information from external agencies? Have the major clinical information systems been down 24 hours? TOTAL YES N O