the following checklist can be used to ... · web viewhe following checklist can be used to...

Arizona Health Care AssociationDISASTER PLANNING GUIDESELF-ASSESSMENT CHECKLISTEXISTING EMERGENCY / DISASTER PLANS EVALUATION

HE FOLLOWING CHECKLIST CAN BE USED TO EVALUATE A FACILITY’S EMERGENCY/DISASTER PLANS AND IDENTIFY OPPORTUNITIES FOR IMPROVEMENT AND ENHANCEMENT.

Facility Name: Address:

Type of Facility:

Skilled Nursing Facility Sub acute-Care Facilities Intermediate-Care Facilities (ICFs) ICFs for the Developmentally Disabled (ICF/DDs) Institute for Mental Health (SNF/STPs) Residential Care Facility for the Elderly (RCFE) Adult Residential Facilities (ARFs) Residential Care Facilities for the Chronically Ill Social Rehabilitation Facilities

Number of Residents: Levels of Care: Name of Person Responsible for Plan:

YES NO N/A1. General Plan Appearance:

a. Appears to be professionally developedb. Utilizes a consistent format throughout the documentc. Utilizes a consistent font throughout the documentd. Appear to be easy to reade. Contained in a well labeled, sturdy binderf. Does not include any damaged pages or sectionsg. Does not include any missing pages or sections

Comments:

2. Plan Organization:a. Includes a comprehensive Table of Contents (TOC)b. TOC appears to be accuratec. Uses tabs for easy referenced. Includes definition section or glossary of termse. Includes “quick reference” sheets that can be easily

copied and distributed for use.

Comments:

of 10


YES NO N/A3. Administrative Elements:

a. Includes Executive Summaryb. Includes language defining the Purpose of the Plan c. Includes language defining the Applicability and Scope of

the Pland. Includes language defining the Legal Authorities and

Referencese. Includes Record of Approval and appropriate signaturesf. Includes Record of Annual Review and appropriate

signaturesg. Includes Record of Changes / Revisions and appropriate

signaturesh. Includes Record of Internal Distributioni. Includes Record of External Distributionj. Includes a comprehensive profile document citing critical

characteristics of the facility

Comments:

4. Plan Updating and Maintenance:a. Master copy of the plan kept in a secure locationb. Copies appropriately distributed throughout facilityc. Copy(s) of plan maintained in a secure off-site location(s)d. Copies of plan distributed to appropriate partnerse. All copies updated on at least an annual basisf. All copies updated whenever significant operational

changes occurg. All copies updated whenever regulatory changes occurh. All copies updated in accordance with After Action Report

findings

Comments:

5. Emergency Planning and Management Concepts:a. References “All Hazards” Emergency Planning and

Managementb. References use of an emergency management model like

the Nursing Home Incident Command System (NHICS)c. References concepts promoted by the National Incident

Management System (NIMS)d. Identifies an Incident Management Team (IMT)

of 10


YES NO N/A5. Emergency Planning and Management Concepts (continued):

a. Is identified as an Emergency Operations Plan (EOP)b. Defines how the EOP is activatedc. Includes organizational chartd. Identifies and defines chain-of-commande. Utilizes NIMS / NHICS-related terminology throughout the

planf. Utilizes NHICS Formsg. Utilizes Job Action Sheets (JAS)h. Identifies location of Nursing Home Command Center

(NHCC) and alternate location(s)i. Defines special codes or phrases for internal broadcast for

different types of emergenciesj. Includes language on Continuity of Operations / Business

Continuityk. Identifies essential services that must be maintained to

ensure resident safety and Continuity of Operationsl. Utilizes a NHICS Kit that includes the following items:

IMT Chart IMT Vests, caps, or other identifying garments JAS Clerical Items: paper, pens, pencils, directories, etc. Communication devices- radios, cell phones Other items needed for NHICS

Comments:

6. Hazard Vulnerability Assessment (HVA):a. Plan includes formal HVA identifying potential threats and

perils b. HVA is updated at least annuallyc. Response protocols in the plan are consistent with the

HVA

Comments:

of 10


YES NO N/A7. Communications:

a. Identifies Modes of Communications: Primary mode of internal communications Back-up mode of internal communications Primary mode of external communications Back-up mode of internal communications Formal relationship with Ham Radio Operator All other modes of communications

b. System to re-call staff during emergencies: Call / phone tree Computerized / Automated System Pre-arranged assignments for select staff to

automatically report to facilityc. Risk communication plan

Comments:

8. Release of Information:a. Identifies those authorized to release informationb. Identifies an official spokesperson(s) and back-up

spokesperson(s)c. Identifies system to release information to the mediad. Identifies system to release information to family

members and responsible partiese. Identifies system to release information to regulators

Comments:

9. Updated Emergency Contact Information - Internal Resources (Citing All Forms of Contact):

a. All contact information is updated on at least a quarterly basis

b. All contact information is updated whenever significant changes occur

c. All contact information is date-stamped showing the most recent update: Executive Staff Supervisory Staff Line Staff and Corporate Staff Residents’ Family / Responsible Parties

Comments:

of 10


YES NO N/A10. Updated Emergency Contact Information - External Resources

(Citing All Forms of Contact): a. All contact information is updated on at least an annual

basisb. All contact information is updated whenever significant

changes occurc. All contact information is date-stamped showing the most

recent updated. Emergency Response Agencies:

Fire Department / Fire Authority Police Department Sheriff’s Department Tribal Law Enforcement Agency State Police Agency- Local Contact Emergency Medical Services Public Works Local / County / Tribal Emergency Management

Agency State Emergency Management Agency

e. Utilities: Electric Natural Gas Propane Gas Public Works Water Sewer Telephone Service – Landlines Telephone Service – Cellular Internet Provider

f. Local Health Departmentg. Local Flood Control Agencyh. State Regulatorsi. Federal Regulatorsj. Insurance Agent(s)k. Insurer Claims Department(s)l. Local Disaster Relief Agency:

Red Cross Salvation Army Charitable Organization

of 10


YES NO N/A10. Updated Emergency Contact Information - External Resources

(Citing All Forms of Contact) (continued):m. Disaster Recovery / Disaster Restoration Providern. Local Ombudsman o. Coroner / Morgue Servicesp. Funeral Home / Mortuariesq. Evacuation Re-location Sites in the Immediate Arear. Other “Like” Facilities in the Immediate Areas. Other “Like” Facilities Outside of the Immediate Areat. Vendors Providing Emergency Assistance:

Emergency Generator Service Contractor Emergency Generator Fuel Service Fire Alarm System Contractor Fire Suppression System Contractor Life Safety Systems Contractor General Contractor Electrical Contractor Plumbing Contractor Board-up Services Food Services Drinking Water Pharmaceuticals Medical Supplies Ambulance Services Transportation Services Truck / Equipment Rental Portable Toilets Other Vendors Providing Essential Services

Comments:

11. Inventory List and location of Emergency Supplies:

Comments:

12. Inventory List and location of Emergency Equipment:

Comments:

of 10


YES NO N/A13. Disaster Menu:

Comments:

14. General Elements of Emergency Procedures Included in the Plan:

a. Categorized by potential threat or perilb. Use a consistent formatc. Are concise and easy-to-readd. Describe specific goals and objectivese. Job tasks are integrated with NHICS protocolsf. Floor plan/sitemap with important features

Comments:

15. Evacuation Planning:a. Evacuation procedures are clearly definedb. Type of evacuation identified:

Horizontal Vertical Complete Facility Evacuation

[c.] Comprehensive evacuation maps / diagrams are posted throughout the facility

c.[d.] External re-assembly locations are identifiedd.[e.] Includes an identification system for residents evacuated

off-site (wristbands, triage tags, face sheets, etc.)e.[f.] Includes an Evacuation Kitf.[g.] Includes an Evacuation Log to track residentsg.[h.] Identifies pre-established off-site temporary evacuation

sites (auditoriums, halls, schools, churches, etc.)h.[i.] Identifies pre-established “like” facilities for longer term

evacuation in immediate areai.[j.] Identifies pre-established “like” facilities for longer term

evacuation outside of the immediate areaj.[k.] Primary evacuation routes identified and includes maps

and directionsk.[l.] Secondary evacuation routes identified and includes

maps and directionsl.[m.] Copies of agreements (transportation, relocation sites,

etc. ) in plan

Comments:

of 10


YES NO N/A16. Sheltering-In-Place Planning:

a. Sheltering-in-Place procedures are clearly definedb. Safe or “hardened” areas in the building have been

identifiedc. Safe or “hardened” areas in the building have been

identified with a sign or placardd. Includes a Sheltering-in-Place Kite. Includes provisions to allow staff and their family to stay

at the facility during a disaster

Comments:

17. Specific Emergency Procedures Included in the Plan:a. Fire / Explosionb. Emergent Severe Weather Events (storms, hurricanes,

tornados, etc.)c. Prolonged Severe Weather Events (excessive cold,

excessive heat, etc.)d. Earthquakee. Heating Failuref. Cooling Failureg. Mechanical Failureh. Fire Protection Systems Failurei. Life Safety Systems Failurej. Emergency Generator System Failurek. Utility Failure:

Electric Natural Gas Propane Gas Public Works Water Sewer Telephone Service – Landlines Telephone Service – Cellular Internet Provider

l. Emergency Shutdown Procedures- Utilities, Mechanical Equipment, Technology, etc.

m. Hazardous Materials Incident- Internal (spill, leak, exposure, etc.)

n. Hazardous Materials Incident- External (spill, leak, exposure, etc.)

of 10


YES NO N/A18. Specific Emergency Procedures Included in the Plan (continued):

o. Missing Resident / Elopementp. Bomb Threatq. Internal / Workplace Violencer. Security Breach s. Facility Lockdownt. Labor Actionu. Civil Disturbance / Riotv. Terror Eventw. Epidemic / Pandemic / Mass Medical Emergencyx. Supply / Delivery Disruptiony. Any peril unique to the facility’s HVA

Comments:

19. Capacity to Handle Deceased Residents or Other:a. Procedures to handle remains of those who have diedb. Temporary morgue identifiedc. Morgue Logd. Supply of Body Bagse. PPE / Universal Precautions

Comments:

20. Post Incident Damage Assessment:a. Defines Damage Assessment Procedureb. Includes Damage Assessment Checklist

Comments:

21. Disaster Recovery:a. Defines Disaster Recovery Proceduresb. Includes system to sequentially reactivate elements of the

operationc. Includes Disaster Recovery Checklistd. Recovery Analysis

Identify strengths Vulnerabilities Opportunities for improvement

Comments:

of 10


YES NO N/A22. Authority to Call for Re-Entry into a Stricken Facility:

a. Defines Authority for Re-Entryb. Describe Re-Entry Procedure

Comments:

of 10

the following checklist can be used to ... · web viewhe following checklist can be used to...

Documents