Continuity of Operations Plan (COOP) Guidelines for Skilled Nursing & Assisted Living Facilities (Name of Facility) Spring 2014 Prepared by Gayle Sherman 165 Piney Creek Road, Reno VN 89511 (415)254 7267
2014 Galena Property Development LLC www.galenapropertyservices.com Limited rights granted to licensee for internal use only. All other rights reserved. Page 2 - Spring 2014
Table of Contents Section 1: General Continuity of Operations Plan Information... 4 A. Executive Summary and Introduction... 4 B. Purpose of Continuity of Operations (COOP) Guidelines... 4 C. Overview of Continuity of Operations Guidelines... 4 D. Continuity of Operations Planning Recommendations... 4 Section II: COOP Elements... 5 A. Alert Notification... 6 B. Alternate Work Facility... 7 C. Delegation of Authority... 8 D. Devolution of Direction and Control... 9 E. Drive Away Kits/Carts... 10 F. Human Capitol... 11 G. Interoperable Communications... 12 H. Mission Essential Functions... 13 I. Orders of Succession... 14 J. Reconstitution... 15 K. Vital Records and Resources... 16 Section III: Plan Maintenance... 17 Update Process... 17 Test, Training and Exercises... 17 Section IV: Background Information... 18 Glossary... 18 Overview of ICS... 21 References and Websites... 22 Hazard Vulnerability Analysis / Risk Assessment... 23 Patient Evacuation Tracking Form... 24 Page 3 - Spring 2014
Section I: General Continuity of Operations Plan Information A. Executive Summary and Introduction The Continuity of Operations Plan (COOP) ensures the continuity of essential functions of Assisted Living and Skilled Nursing facilities (facilities) during any emergency or disaster. A comprehensive COOP includes a number of component parts to meet the needs of various users during any unscheduled event. When an emergency or disaster strikes, organizations must have the capability of continuing critical business functions, possibly in an alternate work location under stressful situations. This guideline provides facilities the tools to develop a COOP. It addresses critical COOP elements; 10 component parts are included for completion to give facilities the ability to stay operational during an emergency or disaster. B. Purpose of Continuity of Operations (COOP) Guidelines The purpose of this COOP guideline is to ensure the continuity of essential functions of the organizations during emergencies created by a variety of natural and man-made and natural disasters when normal standard operations become overwhelmed. The recommendations follow Federal and Health Care procedures to identify recovery strategies that are mission essential and time critical to stay operational after an emergency. C. Overview of Continuity of Operations Guidelines This COOP Guideline is to be used by Assisted Living and Skilled Nursing Facilities during the planning process of identifying critical areas that need to be addressed during any emergency or disaster. An all-hazards approach is used in this guideline, including a worst case scenario in which the facilities are not usable, most staff is not available, and outside assistance is not immediately available. Plan to resume essential functions to an acceptable level within 12 hours and ensure the facilities or alternate facilities can maintain operations for 30 days with external support. D. Continuity of Operations Planning Recommendations To be successful, COOP planning requires upper management support. The organization s leader sets the tone by authorizing planning to take place and directing senior management to get involved. Developing the COOP program is a dynamic process that involves planning, implementation, and validation. Activities in the development of a COOP plan cannot be explicitly defined, but it is important to remember the PROCESS of planning is invaluable. The process is enhanced by Page 4 - Spring 2014
involving all organizational units and levels of staff working in concert. Coordination amongst all functions and organizational levels is important; it implies a willingness to share responsibility and eliminates duplication of efforts. The preparation process includes: 1. Identifying participants from each work group to assist with development of the COOP. 2. Selecting high-level participants who understand the big-picture strategies of the work group. 3. Working as a team to benefit from synergy when including information in the COOP. 4. Developing a schedule to complete the COOP and meet the established deadlines. Section II: COOP Elements For purposes of this guideline, the COOP elements are listed in alphabetical order. Sample formats and examples are provided for your use. In your COOP, prioritize and format the documents as appropriate for your organization. A. Alert Notification B. Alternate Work Facility C. Delegation of Authority D. Devolution of Direction and Control E. Drive-Away Kits F. Human Capitol G. Interoperable Communications H. Mission Essential Functions I. Reconstitution J. Vital Records and Resources Page 5 - Spring 2014
A. Alert Notification When the staff receives an emergency alert, activate the call tree and notify employees and outside organizations. Record contact information for employees, agencies, vendors, consultants, and contractors. Consider including utility providers, licensed independent practitioners and volunteers, and other health care organizations. Employee Contact Information Name and Address Phone Number Email Address Agencies, Vendors, Consultants, and Contractors Contact Information Name, Address, Expertise, and Account Number Contact and Phone Number Email Address Page 6 - Spring 2014
B. Alternate Work Facility Identify a minimum of two locations other than the organization s primary facilities to conduct mission essential functions in the event of COOP activation. This may be a facility that is similar to your facility and allows you to operate under conditions that are not normal. Staff may be split among multiple locations. Refer to Alternate Care Site Plan for relocation of patients/residents. Address Primary Facility Number of Staff/Residents Resources Available / Security and Firewalls in Place Address, Key Contact and Directions Alternate Facility 1 st Choice Number of Staff/Residents Resources Available / Security and Firewalls Available Address & Key Contact and Directions Alternate Facility 2 nd Choice Number of Staff/Residents Resources Available / Security and Firewalls Available Page 7 - Spring 2014
C. Delegation of Authority Identify staff with the authority of conduct business transactions. Determine the delegation of authority in accordance with applicable laws, budget allocations, and administrative directives. Delegation of Authority Travel Authorization: Primary Position: If the person is unavailable, his/her duties are assumed by the following positions 1. 2. Leave Authorization: Primary Position: If the person is unavailable, his/her duties are assumed by the following positions: 1. 2. Purchase Requisitions/Spending Authority: Primary Position: If the person is unavailable, his/her duties are assumed by the following positions: 1. 2. Execution of Contractual Agreements: Primary Position: If the person is unavailable, his/her duties are assumed by the following positions: 1. 2. Page 8 - Spring 2014
D. Devolution of Direction and Control In the event that none of the staff and the facility is available due to the emergency or disaster, designate who or what health care organization can assume the responsibility of the operation of the organization. Organization and decision making person: Devolution of Direction and Control 1. Example: Sister company s staff from another facility outside the region. 2. 3. Page 9 - Spring 2014
E. Drive Away Kits/Carts Identify items to include in drive-away kits. The kits may contain software, databases, forms, and equipment. Pre-position drive-away kits at alternate facilities if possible. Drive Away Kits Equipment, Forms, Documents, Supplies, etc. Example: Contact information for family members of the residents Quantity 1 list Page 10 - Spring 2014
F. Human Capitol Identify human resource requirements for performing essential functions. Identify staff with key skills or experience and available back-up resources. Human resources planning takes into account: Specialized training or skills that are required to perform the essential function; The minimum number of staff required to perform the essential function; and Availability of other staff with skills transferable to support essential functions. Employee Example: Head of Food Services Human Capitol Mission Essential Function Menu planning of meals for residents and staff Skill to Perform Function Knowledge of nutrition and special dietary restrictions of residents Page 11 - Spring 2014
G. Interoperable Communications Interoperable communications include redundant critical communication systems that can be moved to the alternate facility. These systems provide the ability to communicate within the organization and with external emergency responders. Collectively the communication systems provide: Capability commensurate with essential functions; Ability to communicate with essential staff; Ability to communicate with agencies, organizations, patients and other stakeholders; Access to data and systems; Communication systems for use in situations with and without warning; and Ability to support COOP operational requirements The facility will establish and maintain communications between its primary or alternate site and other critical partners using the following methods: Interoperable Communications Equipment Example: Cell Phones Quantity & Location All employees have cell phones they carry with them at all times Page 12 - Spring 2014
H. Mission Essential Functions Following an emergency or disaster, it may not be possible to perform all normal dayto-day tasks. Mission Essential Functions are those functions that must continue by each department to enable the organization to provide vital services, maintain the safety and well-being of the clients, staff and community, and sustain its economic base in an emergency. Identify essential resources required to support the mission essential functions, including staff. Mission Essential Functions to be performed in a One Day disruption Staff Required Resources, Equipment, or Systems Required Examples: Finance Manage payroll Payroll Manager SAP or ADP Food Services Prepare meals Food Services Man., 2 Cooks, 1 Server Chart of dietary restrictions Mission Essential Functions to be performed in a One Day to One Week disruption Staff Required Resources, Equipment, or Systems Required Mission Essential Functions to be performed in a One Week to One Month disruption Staff Required Resources, Equipment, or Systems Required Page 13 - Spring 2014
I. Orders of Succession Develop Orders of Succession for all key positions held within the organization. Establish the official sequence in which one person assumes the roles and responsibilities of a particular function within the organization in the event the usual leadership is unavailable to perform those duties. List the successors by title in order of precedence. Orders of Succession Primary Position: Example: Director If the person is unavailable, his/her duties are assumed by the following positions: 1. Assistant Director 2. Nursing Supervisor 3. Primary Position: If the person is unavailable, his/her duties are assumed by the following positions: 1. 2. 3. Primary Position: If the person is unavailable, his/her duties are assumed by the following positions: 1. 2. 3. Page 14 - Spring 2014
J. Reconstitution Reconstitution is the process by which surviving and or replacement agency staff resumes normal agency operations from the original or replacement primary operating facility. If feasible, restore services at the original facility by making needed repairs, mitigating hazards, restoring utilities, and replacing/repairing damaged equipment. If services cannot be restored at the original facility, identify interim or permanent sites for temporary or permanent restoration of essential services. Health care staff will be kept informed of decisions and progress in restoring services. Staff will also be notified of interim work sites and schedules. 1. Reconstitution Examples: Notify families of the residents, agencies, and vendors of the location and date of the move. 2. Process backlogged transactions. 3. Contact porters or moving vendors. 4. Obtain certificate of occupancy for primary facility if applicable. 5. 6. 7. 8. 9. 10. Page 15 - Spring 2014
K. Vital Records and Resources List the software, documents, equipment, and other resources that are critical to staying operational in an alternate facility. Application, Form, Document, Record, System, or Equipment Example: Payroll records software ADP Vital Records and Resources Location and Back- Up Location On server in facility Backup at corporate Access (Server, Webbased, etc.) Located on D drive on server Page 16 - Spring 2014
Section III: Plan Maintenance Update Process Review and update the information and procedures in the COOP on an annual basis and track revisions. Revision Date Individual Description / Comments Test, Training and Exercises Routine tests, training, and exercises familiarize staff with their roles and responsibilities during emergencies, ensure that systems and equipment are ready to use, and validate certain aspects of the COOP Plan. Staff should use power outages, server crashes, and other ad-hoc opportunities to assess COOP preparedness. Track participation in tests, training, and exercises. Employee Name Date Description of Test, Training, and Exercise Page 17 - Spring 2014
Section IV: Background Information Glossary Activation: When a COOP plan has been implemented whether in whole or in part. Agency Head: The highest-ranking official of the primary occupant agency or a successor or designee selected by the official. Alternate Care Site (ACS): An alternate facility for sheltering residents/patients, generally selected for convenience. Urgent care services and selected traditional inpatient services are not usually provided in the facility, but the facility is deliberately repurposed for the provision of such services during disasters. These locations may alternatively be called Alternate Care Facilities. Alternate Facility: A location, other than the normal facility, used to carry out essential functions in a COOP situation. Continuity of Operations Plan (COOP): The plan describing activities of individual departments to ensure that their essential functions are performed. This includes plans and procedures that delineate essential functions; specify succession to office and the emergency delegation of authority; provide for the safekeeping of vital records and databases; identify alternate operating facilities; provide for interoperable communications; and validate the capability through tests, training, and exercises. COOP Event: Any event that causes an agency or organization to relocate operations to an alternate site or adopt non-standard procedures to assure continuance of its essential functions. Damage Assessment: An appraisal or determination of the effects of the disaster on human, physical, economic, and natural resources. Delegation of Authority: Specifies who is authorized to act on behalf of the organization head and other key officials for specific purposes. Devolution: The capability to transfer statutory authority and responsibility for essential functions from an agency's or organization s primary operating staff and facilities to other employees, facilities, or organizations, and to sustain that operational capability for an extended period. Page 18 - Spring 2014
Drive-Away Kit (Go-Kit): A kit prepared by, and for, an individual who expects to deploy to an alternate location during an emergency. It contains items needed to minimally satisfy personal and professional needs during deployment. Emergency Coordinator: The key senior staff appointed within an organizational element who serves as the coordinator for all emergency response and COOP related matters. Essential Functions: Functions that enable the organization to provide vital services, maintain the safety and well-being of the clients, staff and community, and sustain its economic base in an emergency. Essential Resources: Resources that support the organization s ability to provide vital services, maintain the safety and well-being of the clients, staff and community, and sustain its economic base in an emergency. Hazard Vulnerability Assessment (HVA): The process of identifying potential hazards, threats, and adverse events, and assessing their impact on the operations of an organization. Incident Command System (ICS): A standard management hierarchy and procedures for managing temporary incidents of any size. ICS procedures should be pre-established and sanctioned by participating authorities, and staff should be well-trained prior to an incident. Interagency Agreements: A written agreement entered into between agencies that require specific goods or services to be furnished or tasks to be accomplished by one agency in support of the other. Interoperability: 1. The ability of systems, staff, or agencies to provide services to and accept services from other systems, staff, or agencies and to use the services so exchanged to enable them to operate effectively together. 2. The condition achieved among communications-electronic systems or items of communications-electronics equipment when information or services can be exchanged directly and satisfactorily between them and/or their users. Interoperable Communications: Alternate communications that provide the capability to perform essential functions, in conjunction with other agencies, until normal operations can be resumed. Page 19 - Spring 2014
Mission Critical Data: Information essential to supporting the execution of an agency's essential functions. Mission Critical Systems: Equipment essential to supporting the execution of an agency's essential functions. National Incident Management System (NIMS): A system used in the United States to coordinate emergency preparedness and incident management among various federal, state, and local agencies. Orders of Succession: Provisions for the assumption of senior agency offices during an emergency in the event that any of those officials are unavailable to execute their legal duties. Reconstitution: The process by which surviving and or replacement agency staff resume normal agency operations from the original or replacement primary operating facility. Risk Assessment: The process of identifying potential hazards, threats, and adverse events, and assessing their impact on the operations of an organization Telecommuting Locations: Those locations set up with computers and telephones that enable employees to work at a location closer to their house than their main office. Test, Training, and Exercises (TT&E): Measures to ensure that an agency's COOP program is capable of supporting the continued execution of its essential functions throughout the duration of a COOP situation. Vital Records: Electronic and hardcopy documents, references, and records needed to support essential functions during a COOP situation. The two basic categories of vital records are emergency operating records and legal and financial records. Work-at-home - When an employee carries out their work duties at their residence rather than their official duty station. Page 20 - Spring 2014
Overview of ICS The National Incident Management System (NIMS) was developed so responders from different jurisdictions and disciplines can work together better to respond to natural disaster and emergencies. NIMS use a systematic approach to integrate the best existing processes and methods into a unified national framework for incident management. Incident management refers to how incidents are managed, across all homeland security activities, including prevention, protection, and response mitigation and recovery. The Incident Command System (ICS) provides a management hierarchy and procedures for managing temporary incidents of any size. ICS procedures should be pre-established and sanctioned by participating authorities, and staff should be well-trained prior to an emergency. In the event the Skilled Nursing or Assisted Living Facility needs to respond to an emergency, staff should be identified to serve in the various emergency management roles. To best prepare staff to fulfill their assigned duties during an emergency, and to ensure compliance with FEMA, employees should complete National Incident Management System trainings: IS-100* and IS-700* (or its equivalent) within 90 days of hire IS-200* (or its equivalent) within 1 year of hire ICS Refresher Course or deployment every 2 years. * IS 100, IS 700, and IS 200 are all offered online, and sometimes in a classroom setting. Along with the above listed trainings, staff in certain job classifications should take additional FEMA courses as described below. ICS-300** within 2 years of hire (or notification): ICS-300** and ICS-400** within 2 years of hire (or notification): IS-800.B NRF, within 2 years of hire (or notification): ** ICS 300 and ICS 400 are only offered in a classroom format. Page 21 - Spring 2014
References and Websites http://www.readywashoe.com http://www.fema.gov/planning-templates http://www.fema.gov/continuity-operations East valley Indian health Center Continuity of Operations Continuity of Operations Planning COOP. Florida Power point Presentation Google search: Health Care Continuity of Operations guidelines; several sites are available from other states that have established COOP for their health care facilities, ranging from templates to power point presentations. Page 22 - Spring 2014
Hazard Vulnerability Analysis / Risk Assessment The Statement and Auditing Standard, Number 70 (SAS 70) Business Continuity Planning Guidelines, published in 2002, requires Vulnerability Assessments to consider: A broad range of possible business disruptions, including natural, technical and human threats; The relative probability of occurrence based on a rating system of high, medium, and low; The impact of various business disruption scenarios on both the institution and its customers; and The loss impact on information services, technology, staff, facilities, and service providers from both internal and external sources. Use the following: 0 not likely to occur, 10 highly likely for (A) and (B). Use 0 for prepared, 10 not prepared for (C) Examples below in blue Type of Emergency or Disaster Hazard Vulnerability Analysis (HVA) Worksheet Probability of Occurrence (A) Impact on Facility (B) Level of Preparedness/Preplanning (C) TOTAL SCORE (A)+(B)+(C) Naturally Occurring Events Extreme Cold Winter Storm(Heavy Snowfall, Blizzard) Severe Thunderstorm, High Winds, Hail/Rain Flood (external) Dam Inundation Landslide 1 1 9 11 Extreme Heat Drought Wild Fire Earthquake 8 8 9 27 Plant/Utilities/Technical Events Communication failure Information system failure Electrical failure Generator failure HVAV failure Natural gas failure Sewer failure Page 23 - Spring 2014
Steam failure Water failure Fire/explosion Fire alarm failure Flood (internal) Hazardous materials incident (internal) Structural damage Supply shortage Medications shortage Human Related Events Bomb threat Patient abduction Hostage situation Mass casualty incident Act of terrorism (chemical, biological, radiological/nuclear) Civil disorder (riot/strike) Workplace violence Missing Resident Disease Related Events Epidemic/pandemic/outbreak Anthrax Botulism Plague Smallpox Tularemia VHF Influenza SARS Infections Patient Evacuation Tracking Form Patients/residents being transferred to other facilities must be documented to track where they are going and the information communicated to the Command Center or Regional Emergency Operations Center. Complete the following Patient Evacuation Tracking Sheet in triplicate for distribution as follows: a. Fax or email completed evacuation sheet for each patient/resident to the Medical Unit Leader at Regional Emergency Operations Center; b. Maintain one for your records; and c. Send one with the patient/resident. Page 24 - Spring 2014
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