emergency management program 2017-2018

1 CFHC Board of Directors Approval date: July 25, 2017

Emergency Management Program

2017-2018


Table of Contents

MISSION STATEMENT………………………………………………………………….…….3

PURPOSE………………………………………………………………………………….….….3

ADMINISTRATION…………………….……..………………………………………..……....4

SITUATION……………………………………………………………………………………...5

EMERGENCY PREPAREDNESS PLAN…..………………………….……………………...6

EMERGENCY PROCEDURE – TORNADO……………………………………..…11

EMERGENCY PROCEDURE – FIRE……………………………………………….12

EMERGENCY PROCEDURE – BOMB THREAT………………………………….13

EMERGENCY PROCEDURE – ROBBERY………………………………………...16

EMERGENCY PROCEDURE – HURRICANE……………………………………..17

HURRICANE PREPARATION ASSIGNMENT BY DEPARTMENT…….…..19-23

MITIGATION…..………………………………………………..……………………………..24

COOP PLAN – DEFINITION…………………………………………………………24

CFHC IT DISASTER PREPAREDNESS STATUS AND PLAN…………………..……25-27

ATTACHMENT A: FACILITY PROFILE………………………….……………………….28

ATTACHMENT B: EMERGENCY EXERCISES FORM…………………………………31

ATTACHMENT C: SAMPLE DISASTER CHECKLISTS……………………………..33-38

MISSION STATEMENT


Coastal Family Health Center (CFHC) is a federally qualified health center governed by a

volunteer Board of Directors who are representative of the communities and patients it serves.

Our mission statement is:

“CFHC strives to provide quality comprehensive patient-centered care to the community

regardless of one’s economic status.”

1. PURPOSE

The Emergency Management Program (EMP) establishes procedures by which CFHC can

respond in an informed and organized manner to any situation or critical event that may have the

potential to disrupt services for patients or negatively impact the health center’s ongoing

financial and operational well-being. This EMP also serves to provide procedures for linking the

health center’s resources to the local community response in the event of a natural or man-made

disaster.

Additionally, the purpose of this EMP is to ensure predictable staff behavior during a crisis,

provide specific guidelines and procedures to follow, and define specific roles and

responsibilities. Each site/department within CFHC is expected to develop and maintain an

emergency plan, including a current staff call list. The four phases of emergency management

which are addressed by this plan are mitigation, preparedness, response and recovery.

Scope

The EMP is designed to guide planning and response to a variety of hazards that could threaten

the safety of patients, staff, and visitors, or adversely impact the ability of the facility to provide

healthcare services to the community. The plan is also designed to meet local and state planning

requirements.

The Chief Executive Officer (CEO) and Executive Team (ET) in conjunction with the CFHC

Safety Committee and Facilities Director will be responsible for activating the plan. Any

activation of the plan will be conducted after coordination and consultation with the CFHC

Board of Directors and in conjunction with local emergency management and public health

personnel, if necessary.

Assumptions

The planning assumptions statement shows the limits of the EMP, thereby limiting liability. The

following assumptions delineate what is assumed to be true when the EMP was developed.

Planning assumptions:

Top five hazards are identified.

Identified hazards will occur.


Healthcare personnel are familiar with the EMP.

Healthcare personnel will execute their assigned responsibilities.

Executing the EMP will minimize risks to lives and property.

1. ADMINISTRATION

Executive Summary

The CFHC EMP is an all-hazards plan that outlines policies and procedures for, responding to,

and recovering from possible hazards faced by the organization. Coordination of planning and

response with other healthcare organizations, public health, and local emergency management

are emphasized in the plan. The plan also addresses proper plan maintenance, communications,

resource and asset management, patient care, continuity of operations, management of staff,

evacuation, and contingency planning for utilities failure.

All response activities will follow the National Incident Management System (NIMS) guidelines.

In addition, CFHC will follow the Incident Command System (ICS) organizational structure in

response to emergency events and during exercises. In the event of a community-wide

emergency, CFHC’s incident command structure will be integrated into and be consistent with

the community command structure. Staff will receive training on the ICS system and on their

assigned roles and responsibilities to ensure they are prepared to meet the needs of patients in an

emergency.

Plan Review and Maintenance

The EMP will be reviewed and updated annually incorporating: the latest NIMS elements, data

collected during actual and exercise plan activations, changes in the hazard vulnerability

analysis, changes in emergency equipment, changes in external agency participation, etc. A

corrective action process will be instituted and maintained in the plan to ensure lessons learned

and action items identified from exercises and real events are properly addressed and

documented.

Plan review should also consider changes in contact information, new communications

procedures with the local emergency management agencies, review of evacuation routes and

alternate care sites, and staff and departmental assignments. The review and updates will be

conducted by the CFHC Safety Committee and lead by the Facilities Director, who will also act

as the Department Safety Officer (DSO).


The CFHC Safety Committee will test the facility’s plan and operational readiness at least

annually and will report the results to the Clinical Performance Improvement Team (CPIT), ET,

and CFHC Board of Directors. CFHC will also participate in at least one community mock

disaster drill annually. Also, CFHC must conduct a paper-based, tabletop exercise at least

annually (42 CFR 491.12). This is accomplished through exercises in which many planned

disaster functions are performed as realistically as possible under simulated disaster conditions.

An after-action report/improvement plan (AAR/IP) will be completed within sixty days after the

event. Items/gaps identified in the improvement plan will be incorporated into the gaps of the

emergency operation plan as soon as it is feasible. The CFHC Safety Committee will be

responsible for coordinating the exercises, completing any AARs/IPs and incorporating any

improvements to the plan.

All exercises will incorporate elements of the National Incident Management System and the

Hospital Incident Command System and are Homeland Security Exercise and Evaluation

Program compatible. Information on the Homeland Security Exercise and Evaluation Program

can be found at https://www.preptoolkit.org/web/hseep-resources.

Future exercises should be planned and conducted according to improvement items identified

during previous exercises.

2. SITUATION

Risk Assessment

A Hazard Vulnerability Analysis (HVA) conducted by the CFHC Safety Committee provides

details on local hazards including type, effects, impacts, risk, capabilities, and other related data.

Facility and Mississippi State Department of Health’s Medical HVAs are located in Attachments

1 and 2 of the Continuity of Operations Annex. A template is available for the center HVA and

may be obtained from the Mississippi State Department of Health District Planner. The Medical

HVA can also be obtained from the District Planner.

The top five hazards from facility HVA

A. Tornado

B. Fire

C. Bomb Threat

D. Robbery

E. Hurricane

F. Active Shooter

https://www.preptoolkit.org/web/hseep-resources


3. EMERGENCY PREPAREDNESS PLAN

CFHC must provide for the safety of employees, patients and facilities in case of any emergency.

1. Emergency Evacuation Plan: Contains a list of site/department employees, designates

escape routes, assigns monitors that confirm all employees, patients and visitors are

evacuated and designates an assembly area.

2. Emergency Reporting: Calling 911, contacting supervisor or department head.

3. Bomb Threat Procedures

4. Fire Procedures

5. Medical Emergency Procedures

6. Intra- and inter departmental communications during emergency.

7. Hurricane Procedures

8. Provisions for contacting and coordinating emergency responses with the departments

1.) Security, 2.) General Services and 3.) Department Head (Key Staff).

9. Active Shooter Procedures-deference to Policy http://www.coastalfamilyhealth.org/wp-

content/uploads/2014/02/Active-shooter-policy.pdf for management of active shooter

situation. See attachment D.

Employee Access to Plan

Each employee is to receive a copy of the EPP. The plan should be kept at hand and the

employee should take the plan with them when evacuating the facility. The plan will also be

posted and maintained on the CFHC intranet.

Employee Training

All employees should be trained on each of the component of the EPP. Plan should be reviewed

with new employees at the time of hire. New employees are to be shown fire extinguishers and

first aid kit location and are to be walked through the department’s evacuation route.

Site Safety Officer (SSO)

http://www.coastalfamilyhealth.org/wp-content/uploads/2014/02/Active-shooter-policy.pdf

http://www.coastalfamilyhealth.org/wp-content/uploads/2014/02/Active-shooter-policy.pdf


The SSO is responsible for insuring that evacuation plans are posted and for maintaining a list of

employees requiring assistance if the facility is evacuated and functions as the department’s

point of contact during an emergency.

Incident Response Team

Sites/departments may designate specially trained employees to respond to specific types of

emergencies…i.e medical emergencies, trained in CPR, when responding to a customer/patient

or employee with cardiac or respiratory distress.

Inter and Intra Department Communication

Clinic or administrative sites with multiple departments (large complex) should coordinate and

determine a method for notifying all departments of an emergency or threatening situation in

another area of the facilities.

Evacuation Drills

SSO is responsible for coordinating and documenting these drills.

Evacuation Assembly Area

Site/Department supervisors will consult with the SSO when identifying evacuation assembly

areas.

Reporting Emergencies

Police, Fire or Medical Emergency

Any staff responding to an emergency situation must first dial 911. Remember on CFHC phones

you must dial “9” (9-911). Be prepared to provide emergency dispatchers with the following

information:

1. Type of emergency (fire, medical, police)

2. Scope of the emergency (size of problem)

3. Location – Be as specific as possible.

A. Name of city

B. Address

C. Name of business

D. Any other information that best describes the location

4. Your name, phone number you are calling from in case they need more information

from you.


5. Any other details that the emergency responders may need to know.

6. You may have to stay on the line with the emergency operator for the responding

team to ask more questions.

7. After instructed to hang-up, please contact supervisor to report the incident.

Emergency Evacuation Plan

If you are directed to evacuate the building, follow the (EEP) Procedure:

Why evacuate: The most obvious is when a fire, bomb threats and toxic fumes threatens the

safety of the employees or patients, bomb threats and toxic fumes.

1. Fire Alarm: Evacuation should begin immediately without questions whether or not it

is a false alarm.

2. Bomb Threats: When there is enough information to believe it is not a hoax.

3. Toxic fumes: When there are strange odor/fumes present that may indicate toxic

fumes.

When not to evacuate: There may be situations where it is more dangerous to leave the building

than to stay inside.

1. Weather, Severe – Tornados, strong winds, flooding, etc.

2. Chemical Spills – Shut off ventilation system, close all doors and windows.

3. Plane Crash – Toxic fumes

4. Active Shooter

Know Your Emergency Exits

Learn the location of all exits. Practice an evacuation on your own. Be aware of all available

exits in the event the regular ones become unusable. CFHC is required to have an evacuation

plan diagram posted with emergency exits clearly indicated.


Evacuation Assembly Area

Each CFHC department/facility should have a designated assembly area. Once the evacuation

order is given, proceed directly to that area. Remain there until told to do otherwise.

Evacuation Drills

You are expected to participate in evacuation drills. These drills are conducted to familiarize

you with the emergency exits and evacuation procedures and to help identify problem areas.

Hallways and Exits

To make sure you will be able to use exits during an emergency, follow these guidelines:

1. Hallways and exits must be free of obstructions

2. Storage of any kind is not permitted in the hallways even on a temporary basis. This

means boxes, files, furniture, etc.

3. Stairs and stairwells are not storage areas.

4. Do not allow chairs, trash cans or other furnishings to block exits.

5. Exits should be clearly identified with “EXIT” signs. If an exit sign is not properly

lit, report it immediately to your supervisor, department head or Facilities Manager.

6. Electric cords and telephone/computer cables should not lie across an aisle where

they may present a tripping hazard.

7. No door should be wedged open. Especially fire doors.

Evacuation Procedures

1. When the alarm goes off or an announcement is made by the department

head/supervisor/emergency personnel, all staff, patients and visitors will immediately

exit and evacuate the facility in an orderly fashion with no running.

2. Repeat of above

3. Do not go against the flow of people exiting.

4. Evacuate through exits closest to where you are located.


5. Stairs should be used and not elevators, to reach the first floor.

6. If a person is injured, disabled or otherwise unable to use the stairs, they should wait

in the stairwell for assistance from emergency personnel. If any staff, patients or

visitors remain in the stairwells because they are unable to use the stairs, this

information should be reported ASAP to the emergency personnel.

7. All staff and patients are to report to assembly area until notified by emergency

personnel.

8. All staff, patients and or visitors should remain in the assembly area until given a

specific task or release by their supervisor or SSO representative.

9. The SSO representative for that facility should check the following areas:

A. Office space and work stations

B. Conference rooms

C. Restrooms

D. Break rooms

E. Stairwells

F. Patient rooms

G. Any other clinic area

10. For larger clinics, SSO team members may be designated, with each member of the

team assigned a specific area to check.

11. After all rooms/areas are checked, only the SSO representative(s) will make sure that

all doors are closed/secured and will check off each area on a designated checklist.

12. Once staff, patients and visitors are in their designated meeting areas and everyone is

accounted for, the site supervisor or SSO representative(s) will do a roll call or head

count and report to the SSO.

All Staff

1. Take your EPP binder with you. Anyone’s copy of the employee list can be used for

taking roll call, for logging any assignments individual or group may be given to do.

2. Take your pocket book, purse, identification, car keys, etc.


EMERGENCY PROCEDURE – TORNADO POLICY: In order to ensure the safety of patients and staff in the event of a tornado, a

standardized emergency plan will be followed.

PURPOSE: To protect the lives of patients and staff in the event of a tornado strike to one or

more CFHC locations.

PROCEDURE:

1. Upon hearing an approaching tornado, the staff should quickly and calmly direct all

patients and proceed themselves into the interior hallway on the lowest floor of the site

and as far away from doors and windows as possible.

2. The patients and staff should be instructed to sit on the floor as close to the walls as

possible. They should also be told to cover their heads with their hands.

3. All staff and patients should remain in this position until the tornado has left the area and

the all clear has been given by the department head, supervisor, or emergency personnel.

4. After calming the patients, the department head, supervisor or the clinic’s SSO

representative/team should call the Administrative Offices for further instructions and a

weather update.


EMERGENCY PROCEDURE – FIRE

POLICY: In the event of a fire, the safety of the patients and staff should be insured and

property protected to the greatest extent possible.

PURPOSE: To protect the lives and safety of patients and staff and minimize property

damage.

PROCEDURE:

1. The employee who first encounters the fire should announce “FIRE” to advise the

other staff members, activate fire alarms if available, and immediately call 911.

2. Staff should begin evacuation of patients and themselves from the building.

3. If the fire is contained to a small area, i.e., trash can, electrical appliance, etc., the

nearest fire extinguisher should be used to extinguish the blaze.

4. The site supervisor or SSO will notify a member of the ET.

5. After the fire is extinguished, and should the Fire Department deems the building

safe, the site supervisor or the clinic’s SSO representative/team should notify a

member of the ET and report the extent of the fire and the extent of damage.


EMERGENCY PROCEDURE – BOMB THREAT

POLICY: Information regarding received bomb threats should be documented on the Bomb

Threat Checklist.

PURPOSE: To provide adequate information for authorities.

PROCEDURE:

1. The staff member receiving the threat should try to remain calm and write

down any information that the caller gives using the Bomb Threat Checklist

Form.

2. Immediately after the caller has hung up, the staff member should call 911 and

report the incident to emergency authorities and to the site supervisor or the

clinic SSO representative/team

3. The site supervisor or the clinic’s SSO representative/team should

immediately notify a member of the ET.

4. The same reporting person should follow the guidance of local enforcement

officials.

5. If directed to evacuated, the staff should calmly and quickly direct patients out

of the building and staff should exit the building as requested.

6. After the law enforcement officials verify the safety of the building, patients

and staff may re-enter.

7. The site supervisor or SSO will update a member of the ET of the re-entry

authorization and complete and submit an incident report.


ATTACHMENT: BOMB THREAT CHECKLIST

TELEPHONE BOMB THREAT CHECKLISTINSTRUCTIONS:

LISTEN. DO NOT INTERRUPT THE CALL EXCEPT TO ASK:

WHEN WILL IT GO OFF? Certain Hour________ Time Remaining________

WHERE IS IT PLANTED? Building________ Area________

WHAT DOES IT LOOK LIKE? _______________________________________________

Did caller appear familiar with building by his description of the bomb location? Yes___No___

Name of Receptionist______________________________ Time of Call________Date________

Caller’s Identity

SEX: Male________ Female________ Approximate Age________

ORIGIN OF CALL

____Local ____Long Distance ____Booth ____Internal (from within bldg)

VOICE CHARACTERISTICS SPEECH LANGUAGE

___Loud ___Soft ___Fast ___Slow ___Excellent

___Good ___Distinct ___Distorted ___Fair

___High Pitch ___Deep ___Stutter ___Nasal ___Poor

___Raspy ___Pleasant ___Slurred ___Other ___Foul

___Intoxicated___Other Use of certain words or phrases

ACCENT MANNER BACKGROUND NOISES

___Local ___Not Local ___Calm ___Angry ___Office Machines

___Foreign ___Regional ___Rational ___Irrational ___Factory Machines

___Race ___Other ___Coherent ___In Coherent ___Bedlam ___Trains

___Deliberate ___Emotional ___Animals ___Voices

___Righteous ___Laughing ___Quiet ___Music

___Mixed ___Party

___Street Traffic


ACTION TO BE TAKEN IMMEDIATELY AFTER CALL

FIRST: CALL 911 AND THEN REPORT THREAT TO PM OR SSO

SECOND: WRITE OUT THE MESSAGE IN ITS ENTIRETY AS RECEIVED FROM THE

INFORMANT:_________________________________________________________________

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REMARKS:

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A. EMERGENCY PROCEDURE – ROBBERY

POLICY: Employees are to fully cooperate with anyone attempting a robbery.

PURPOSE: To minimize the risks to the staff and patients during any robbery attempt.

PROCEDURES:

1. If approached by an individual and attempting to rob the site, regardless of whether or not

a weapon is visible or not the employee should remain as calm as possible.

2. The employee should listen carefully to the Robber’s request.

3. The employee should comply with the request.

4. The employee should pay close attention to the robber to look for distinguishing

characteristics to provide an adequate description to law enforcement officials.

5. After the robber leaves the area or building, the affected employee should immediately

call 911 and report to local law enforcement officials. The site supervisor or SSO should

also be notified along with a member of the ET.

6. After law enforcement officials leave, a member of the ET should be advised of their

findings and an incident report completed.


EMERGENCY PROCEDURE – HURRICANES

POLICY: In order to ensure the safety of patients and staff and to protect facilities and resources

in the event of a tropical event i.e. hurricane or flood, a standardized emergency plan will

be followed.

PURPOSE: To protect the lives of patients and staff and protect properties in the event of a

tropical storm, hurricane impact, or other natural disaster affecting one or more CFHC

locations.

PROCEDURES:

Preparedness includes all activities undertaken to ensure facilities have the necessary resources

available to effectively respond to an incident.

As part of this plan, each clinic location should have a written employee recall system in place.

Should employees be released due to the threat of a disaster, the recall system will be put into

action after the disaster to advise employees of the status of operations and when to report back

to work.

In order to meet responsibilities of CFHC in a natural disaster, it is essential that the tasks

outlined on the attached pages be properly carried out. The tasking periods are as follows:

1.) Hurricane Alert

2.) Hurricane Watch

3.) Hurricane Warning

4.) 12 hours to landfall

Terms to know:

Hurricane Alert: Is issued when a hurricane may threaten the coastal areas within 48-72 hours.

Hurricane Watch: Is issued for areas when there is a threat of hurricane conditions within 24-36

hours.

Hurricane Warning: Is issued when hurricane conditions are expected in specific coastal areas in

25 hours or less. Hurricane conditions include winds of 74 miles per hour (64 knots) and/or

dangerously high tides and waves. Actions for protection of life and property should begin

immediately when the warning is issued.

Tornado Watch: Conditions are favorable for the formation of a tornado in the immediate area.

Tornado Warning: A tornado has been spotted in the area.

Severe Thunderstorm Warning: A severe thunderstorm is in the area.


Flash Flood: A rapid rise in water level to above flood stage with associated rapid current.

Flood and Flash Flood Watch: Conditions are favorable for flooding or flash flooding in the

immediate area.

Flood and Flash Flood Warning: Flooding has developed in the immediate area.

The tasks have to remain flexible due to the unpredictability of hurricanes. The times and tasks

guidelines are as follows:

Hurricane Alert – 72 Hours to Hurricane

1. Monitor weather conditions

2. Review the destination of staff and contact information.

3. Review emergency arrangements for family and home.

4. Inventory medical and other supply requirements and arrange storage.

Hurricane Watch – 48 Hours to Hurricane

1. Monitor weather conditions.

2. All staff makes plans for families and home.

3. Supervisors meet with Executive Director with at least one representative from each

clinic.

4. Review plan with staff and implement assignments as needed.

5. Make arrangements to secure all clinics including equipment and supplies.

6. Coordinated with Greene, Wayne, Hancock, Harrison, and Jackson County Civil

Defense.

Hurricane Warning – 24 Hours to Hurricane

1. Monitor weather conditions.

2. Prepare to suspend all activities for the public as conditions indicate.

3. Account for all staff.

4. Supervisors plan time to release all non-essential staff as dictated by conditions. CEO

will determine time for release of all personnel.

5. Make arrangements to safeguard vaccines and other perishables.

6. Ensure all facilities have been secured.

12 Hours to Hurricane Landfall

1. Monitor weather conditions

2. CEO or designee, walk through facilities to ensure buildings have been properly

secured.

3. Release all staff


4. Supervisors should have shelter plans and contact numbers for all personnel they

supervise.

5. Supervisors continue communication with the ET.

Post-Hurricane

1. Place recall plan in action to account for all personnel.

2. Supervisors notify personnel when clinics will reopen.

HURRICANE PREPARATION ASSIGNMENTS BY DEPARTMENT

POLICY: Employees are to follow the stated guidelines set forth in preparation of a hurricane.

PURPOSE: To protect the safety of the staff and patients.

PROCEDURE:

1. Pre-designated areas are away from windows and exterior doors and off the floor, if

possible.

2. All employees will assist in the preparations for a hurricane and will assist other staff

members to ensure that all preparations are completed prior to departure from their

assigned workplaces.

3. All employees will advise their immediate supervisor of their plans for the hurricane

including destination telephone number. It will be expected that employees can, and

will, return to work as required.

4. Each employee will try to ensure that any patient requiring medical attention will

receive it prior to departure from the clinic.

5. Each employee will follow the process of the call-tree protocol

6. All employees are expected to return to work at the time given.

Mobile Unit Staff

1. Take all moveable items off the floor in the mobile unit and secure within designated

areas.


2. Secure all equipment items which are in danger including audiometers, EKG’s,

Dopplers, etc., by moving them to the designated secure area, covering them with

polyvinyl covering and securing with tape.

3. Computers that cannot be removed from the mobile unit will be protected with

polyvinyl covering and secure with tape. Any computers that can be removed will be

secured in a designated location.

4. Designated clinic staff will ensure that SolutionReach inclement weather messages

are sent to patients on each clinic’s schedule in order to cancel appointments during

the time of threat.

5. The mobile unit will be stationed in a pre-designated area until the storm is over.

When conditions are safe, the mobile unit will be utilized as an emergency clinic until

the remaining clinics are open.

Provider Staff

1. After consultation with the Chief Medical Officer (CMO), Providers will advise staff

of their instructions for patients.

2. The provider on-call for each rotation at the time the hurricane warning is issued will

be required to handle after hours calls and emergencies. Any deviation from this

procedure must be approved by the CMO.

3. The answering service should reference the on-call schedule provided to them

monthly by the Medical Staff Coordinator.

4. Providers will identify high risk patients to be contacted by staff for medication refills

and other care.

5. Refills should be issued and follow-up appointments made for those patients on

schedule for the day and following day.

6. Working with the Nursing Team Leader, all items requiring refrigeration will be

taken to a secure place with a commercial refrigerator and generator for storage in

accordance to the CS-NUR 4.3 Medication/Vaccine Transport policy.

Nursing

1. Take all moveable items off the floor in the exam rooms.


2. Secure all equipment items which are in danger including audiometers, EKG’s,

Dopplers, etc., by moving them to the designated secure area, covering them with

polyvinyl covering and securing with tape.

3. Exam room computers will remain where they are stationed. They will be protected

with polyvinyl covering and secure with tape.

4. Designated clinic staff will ensure that SolutionReach inclement weather messages

are sent to patients on each clinic’s schedule in order to cancel appointments during

the time of threat.

5. Designated clinic staff will call all Obstetrics (OB) patients at 32+ weeks of gestation

to ensure that referral arrangements are made with the designated hospital for any OB

emergencies.

6. Assist in the packaging of any perishable items to be transported to safer quarters

including all injectable medications.

Laboratory

1. Disconnect from power source all laboratory equipment after turning the equipment

off. This includes all electronic devices.

2. Cover all equipment with polyvinyl covering and secure with tape.

3. Remove all legal documents to elevated area and cover with polyvinyl.

4. Coordinated removal of all perishable items with Medical and Nursing Team Leaders.

Dental

1. Unplug and turn off all electrical appliances.

2. Cover all water sensitive items with polyvinyl covering and secure with tape. Cover

curing light with plastic and place inside of utility cart.

3. Cover all computer hardware, copy machine, with polyvinyl covering and secure with

tape.

4. Move all items on counter tops inside the cabinets.


WIC Staff

1. Copy the appointment schedule for the next week. Place the appointment schedule in

the safe. Take the copy of the schedule off-site.

2. Call all patients with appointments for the remainder of the day and reschedule as

appropriate. Call patients with appointments the following day to ask them to listen

to TV and radio for instructions. They may also call the answering service.

3. Return all medical records to the medical records department.

4. Move all office equipment to the pre-designated secure area, cover with polyvinyl

covering and secure with tape.

Social Workers


2. Assist in identifying high risk infants, frail, elderly patients and others at high risk and

coordinate directions for them with their attending clinician.

3. Cover all office equipment with polyvinyl covering and secure with tape.

Pharmacy


2. Ensure that all refrigerated medications are secured in accordance to the Medication

Transport and Storage policy.

3. Move all electronica equipment to a designated area, cover with polyvinyl and secure

with tape.

4. Cover all office equipment with polyvinyl covering and secure with tape.

PSRs/Front Desk Staff

1. Print a copy of the appointment schedule for the next week. Place the appointment

schedule in the safe. Take the copy of the schedule off-site.

2. Empty cash drawer, after verification of the day’s activities, and place all cash on

hand, including Drinks and Refreshment fund money and petty cash, in the safe.


3. Call all patients with appointments for the remainder of the day and reschedule as

appropriate. Call patients with appointments the following day to listen to TV and

radio for instructions. They may also call the answering service.

4. Remove all medical records from the bottom shelf if less than four inches off floor.

Place in boxes and store boxes on desks or tables. Cover all records with polyvinyl

covering and secure with tape.

5. All loose records from provider offices should be secured in trash bags or boxes and

placed in a secure location off the floor.

6. All office equipment and electrical appliances should be turned off, unplugged and

covered with polyvinyl.

7. Upon completion of verification of the day’s activities, all computer equipment

should be turned off, unplugged. All equipment items should be off the floor and

covered with polyvinyl covering, secured closed with tape. Cords and cables should

be unplugged from the walls, but should remain attached to the equipment. The

cables should be taped in the “figure 8” fashion, not twisted. The cables can be

labeled by writing on masking tape attached if needed. Connectors on the back of

terminals and printers should remain on the respective equipment pieces. In clinics

with multiple printers and terminals, the taped bags should be marked with the name

of the office from where it came. If terminal cables are unplugged from the rear of

the multiplexers or the CPU, the cables should be marked to identify the port or

connection. Keyboards should be marked with the same label as the terminal green

label.

All Staff

1. Ensure that all loose objects, if any, are secured inside the building.

2. Make sure all blinds are closed.

3. Secure any Center vehicle as appropriately as possible.

4. If no phone service, listen to TV and radio for instructions.

5. Ensure that all legal papers are moved to a safe/secure location to reduce the

probability of water damage.

6. Ensure that all money collected from patients is turned in to the CFO.


MITIGATION

Mitigation activities lessen the severity and impact a potential disaster or emergency might have

on a health center’s operation.

Coordination with Mississippi Department of Health.

Coordination with local Emergency Management Agency (EMA) and/or Civil Defense Director

as well as Mississippi Emergency Management Agency (MEMA).

Coordination between and among hospitals.

Coordination with the Primary Care Association(PCA), community health clinics and

physician’s offices (as applicable).

Coordination with federal health facilities (VA, Military, etc.).

Coordination with local and regional emergency medical services (Ambulance Services/EMS).

Coordination with local, county, and state law enforcement agencies.

COOP PLAN DEFINITION

COOP is a plan that details how essential functions of a facility will be handled during any

emergency or situation that may disrupt normal operations.

All Key Staff will have a copy of the COOP to refer to in case of a disaster.


COASTAL FAMILY HEALTH IT DISASTER PREPAREDNESS STATUS PLAN

A. The IT assets critical to the ongoing operation of Coastal’s business are:

1. The telephone system at each site.

2. The telecom communication routers, site connections to a central telephone office and

the network that ties all the fixed facilities together for inter site telephone service and

for centralized systems such as Practice Management. The central hub location for

the network is now in the data centers located in Hattiesburg MS and Birmingham

AL.

3. The centralized computer system servers where the NextGen Practice Management

System, GMS Financial System, GHG and Attendance System, central call center

IPC server. The server’s reside in the administration building data center.

4. The PM system and EMR systems reside in a SAS70 certified data center located in

Hattiesburg, MS and replicated to a disaster recovery site also SAS70 certified, in

Birmingham, AL. The primary and disaster recovery center data centers have backup

power, air conditioning and redundant network connections.

B. The effect of losing the service of each one of these assets is outlined below. Keep in

mind that loss of more than one asset is cumulative in its affect!

1. Telephone system:

a. Single Site

i. No calls in or out of affected site

ii. No telephone service within the site

iii. All directories, email or other VOIP based systems inoperable for that site.

b. Multiple Sites (in addition to Single Site)

2. Telecom router(s)

3. Site Connection to Local Telephone Office

4. Network

5. Practice Management System and Server


6. GMS server/desktop

7. Electronic Medical Records System and Server

8. Central Call Center IPC Server

9. MS Exchange email server

C. Possible incident scenarios causing loss or interruption in service are:

1. Computer, router equipment failure.

2. Power failure

3. Air conditioning failure

4. Vandalism

5. Facility infrastructure or access failure (fire, broken water pipe, other)

6. Natural disaster (hurricane, tornado, earthquake, flood)

7. Other

D. Mitigation, recover and exposures from incidents at the present time:

1. Backup procedure now in place:

a. GMS system and data backed up on CD ROM and placed offsite by the CFO or

other staff daily. If total GMS is lost?

b. Practice Mgmt. system and data backed up on tape and placed offsite by IT staff

daily. If total server is lost, NextGen can setup a new system in 72 hours.

c. Critical production files on desktops? All users have remote drive for data in the

admin data center which is backed up to tape nightly and the tape removed to

offsite by the IT staff.

d. Other – GMS, Phone servers, Practice Management, Electronic Medical Records,

Time and Attendance and IPC Call center servers will be removed from Admin

and placed in the D’Iberville, MS building.

2. Exposures


a. Backup site for data is TekLinks data center in Hattiesburg MS and Birmingham

AL.

b. Time to recover is based on replacing local hardware and restoring internet

access.

c. Who is responsible/accountable for backups?

PM, EMR, systems and data reside on the Cloud

All data systems are backed tape, CD ROM or USB removable drivers and

removed from the facility to offsite locations by the IT staff or the CFO.

d. Other exposures…

E. Strategy and plan to further reduce risk and impact of incidents.

a. Document and practice recovery scenarios

b. Redundant servers in other physical locations with backup databases updated “on

the fly”

F. High level project plan and resource estimates.

a. Project sponsor – Executive Director

b. Project Leader – IT Director

c. Project members – Finance officer, COO, Medical Director


Attachment A: Facility Profile

Facility Profile (to be completed by each location and filed with EPP)

Facility Name:

Address:

County:

Phone: Fax:

Emergency Phone:

Owner/Corporation:

Address:

Phone: Secondary Phone:

Emergency Phone:

Facility Administrator:

Address:


Emergency Phone:

Emergency Operations Plan Coordinator:


Address:


Emergency Phone:

Number of Examination Rooms:

Specialty Services or Units:

Table 1: Primary and Affiliate/Sister Facilities

Primary Facility

Facility Name Address (Street, City, State, Zip) County

Affiliate/Sister Facilities

Facility Name Address (Street, City, State, Zip) County

Note: See Attachment E for more information.


Signature Page

<Insert Facility Name>

______________________________________ _________________

Name, Title Date

______________________________________ _________________

Name, Title Date

Mississippi State Department of Health, Office of Emergency Planning and Response

District Level

______________________________________ _________________

Emergency Planner Date

______________________________________ _________________

Emergency Response Coordinator Date

______________________________________ _________________

Emergency Preparedness Nurse Date


Attachment B: Emergency Exercises Form

Table 1: Exercises Conducted

Type of Exercise Hazard Exercised Date of Exercise After Action Review

Completed

Authorities and References

<Insert title and date of local city and/or county emergency operations plan >

<Insert titles of other organizational plans or policies that have a connection to the

emergency operations plan>

Mississippi Emergency Management Agency (MEMA)

http://www.msema.org/

National Incident Management System (NIMS)

Federal Emergency Management Agency (FEMA)

https://www.fema.gov/national-incident-management-system

Incident Command System (ICS)

FEMA

https://www.fema.gov/incident-command-system-resources

Strategic National Stockpile

Centers for Disease Control and Prevention

http://www.cdc.gov/phpr/stockpile/index.htm

http://www.msema.org/

https://www.fema.gov/national-incident-management-system

https://www.fema.gov/incident-command-system-resources

http://www.cdc.gov/phpr/stockpile/index.htm


Mississippi Responder Management System

Mississippi State Department of Health

https://signupms.org/index.php

Centers for Medicare & Medicaid Services (CMS)

http://www.cms.gov

Disaster Resiliency and NFPA Codes and Standards

Refer to the National Fire Protection Association (NFPA) Standards in NFPA 101 Life

Safety Code, and NFPA 1600, Disaster/Emergency Management and Business Continuity

Programs

Mississippi Emergency Access Program (MEAP)

http://www.dps.state.ms.us/divisions/office-of-emergency-operations/mississippi-statewide-

credentialing-access-program/

https://signupms.org/index.php

http://www.cms.gov/

http://www.dps.state.ms.us/divisions/office-of-emergency-operations/mississippi-statewide-credentialing-access-program/

http://www.dps.state.ms.us/divisions/office-of-emergency-operations/mississippi-statewide-credentialing-access-program/


Attachment C: Employee Supply Checklist

INFORMATION FOR EMPLOYEES – SAMPLE DISASTER CHECKLISTS

FIRST AID CHECKLIST

SUPPLIES HOME (CHECK) VEHICLE (CHECK)

Adhesive bandages, various sizes

Germicidal hand wipes or

waterless, alcohol based hand

sanitizer

Antiseptic wipes

Pairs large, medical grade,

non-latex gloves

Antibacterial ointment

Adhesive tape, 2” width

Cold pack

Scissors (small, personal)

Tweezers

Assorted sizes of safety pins

Cotton balls

Thermometer

Sunscreen

First aid manual


NON-PRESCRIPTION AND PRESCRIPTION MEDICINE KIT


Aspirin & non-aspirin pain reliever

Anti-diarrhea medication

Antacid (for stomach upset)

Prescriptions

Extra eyeglasses/contact lenses

SANITATION AND HYGEINE SUPPLIES

SUPPLIES HOME (CHECK)

Washcloth and towel

Towelettes, soap, hand sanitizer

Toothpaste, toothbrushes

Shampoo, comb, brush

Deodorants, sunscreen

Lip balm, insect repellent

Contact lens solution

Feminine hygiene supplies


EQUIPMENT AND TOOLS

TOOLS CHECK KITCHEN ITEMS CHECK

Portable, battery-powered

radio or television and extra

batteries

Manual can opener

NOAA Weather Radio, if

appropriate for your area

Mess kits or paper cups,

plates, and plastic utensils

Flashlight and extra batteries All-purpose knife

Signal flare Household liquid bleach

to treat drinking water

Matches in a waterproof

container (or waterproof

matches)

Sugar, salt, pepper

Shut-off wrench, pliers,

shovel, and other tools

Aluminum foil and plastic

wrap

Duct tape and scissors

Re-sealable plastic bags

Plastic sheeting Small cooking stove and a

can of cooking fuel (if

food must be cooked)

Whistle

Small canister, ABC-type fire

extinguisher

Comfort items

Tube Tent Games

Compass Cards

Work gloves Books

Paper, pens, and pencils

Toys for kids

Needles and thread Foods

Battery operated travel alarm

clock


FOOD AND WATER


Water

Ready-to-eat meals, fruits, and

vegetables

Canned or boxed juices, milk,

and soup

High-energy foods such as

peanut butter, jelly, low-

sodium crackers, granola bars,

and trail mix

Vitamins

Special foods for infants or

persons on special diets

Cookies, hard candy

Instant coffee

Cereals

Powdered milk


DOCUMENTS AND KEYS

Make sure you keep all of these items in a watertight container

ITEM STORED (CHECK)

Personal identification

Cash and coins

Credit cards

Extra set of house keys and car keys

Copies of the following:

Birth Certificates

Marriage Certificates

Driver’s Licenses

Social Security Cards

Passports

Wills

Deeds

Inventory of household goods

Insurance papers

Immunization records

Bank and Credit Card account numbers

Stocks and Bonds

Emergency contact list and phone numbers

Map of area and phone number of place you

could go


Related Links/Forms/Policies:

Risk Management and Safety

1. OP-FAC 2.0 Active Shooter Plan

2. OP-FAC 3.0 Emergency Clinic Closing Notifications

Medication/Vaccine Safety

1. CS-NUR 4.3 Medication/Vaccine Transport

2. CS-NUR ML.0 Vaccine Inventory Management

HIT/Data Backup

1. OP-IT 9.1 Data Center Backup and Recovery

2. OP-IT 13.1 Security Risk Analysis

emergency management program 2017-2018

Documents