Technical Assistance Publication Series

TAP 34
 

Disaster Planning

Handbook for 

Behavioral Health 

Treatment Programs 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Substance Abuse and Mental Health Services Administration 

Center for Substance Abuse Treatment

1 Choke Cherry Road 

Rockville, MD 20857

Disaster Planning Handbook 

for Behavioral Health 

Treatment Programs 

TAP 

Technical Assistance Publication Series 

34 
Disaster Planning Handbook for Behavioral Health Treatment Programs

ii 

Acknowledgments 

This publication was prepared for the

Substance Abuse and Mental Health Services 

Administration (SAMHSA) by the Knowledge

Application Program, a Joint Venture of The

CDM Group, Inc., and JBS International,

Inc., under contract number 270-09-0307, 

with SAMHSA, U.S. Department of Health

and Human Services (HHS). Christina

Currier served as the Contracting Officer’s

Representative. 

Disclaimer 

The views, opinions, and content of this

publication are those of the authors and do

not necessarily reflect the views, opinions, or

policies of SAMHSA or HHS. 

Public Domain Notice 

All materials appearing in this document

except those taken from copyrighted

sources are in the public domain and may

be reproduced or copied without permission

from SAMHSA or the authors. Citation 

of the source is appreciated. However,

this publication may not be reproduced or

distributed for a fee without the specific,

written authorization of the Office of 

Communications, SAMHSA, HHS. 

Electronic Access and Copies 

of Publication 

This publication may be ordered or

downloaded from SAMHSA’s Publications 

Ordering Web page at http://store.samhsa.gov. 

Or, please call SAMHSA at 1-877-SAMHSA-7

(1-877-726-4727) (English and Español). 

Recommended Citation 

Substance Abuse and Mental Health Services 

Administration. Disaster Planning Handbook 

for Behavioral Health Treatment Programs.

Technical Assistance Publication (TAP) Series

34. HHS Publication No. (SMA) 13-4779.

Rockville, MD: Substance Abuse and Mental 

Health Services Administration, 2013. 

Originating Office 

Quality Improvement and Workforce

Development Branch, Division of Services

Improvement, Center for Substance Abuse

Treatment, Substance Abuse and Mental 

Health Services Administration, 1 Choke 

Cherry Road, Rockville, MD 20857. 

HHS Publication No. (SMA) 13-4779

Printed 2013 
iii 

Contents
 

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
 

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
 

Audience for This TAP.................................................... xiii
 

Organization of This TAP ..................................................xiv
 

Behavioral Health Terms ..................................................xiv
 

Disaster Terms........................................................... xv
 

Chapter 1—Rationale and Process for Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
 

Essential Partners in National Preparedness ................................... 1
 

Providers of Essential Services ............................................... 2
 

Partners in Community Preparedness ......................................... 3
 

Mandates for Disaster Planning .............................................. 3
 

All-Hazards Planning ...................................................... 4
 

The Planning Process ...................................................... 4
 

Continuity Planning ....................................................... 5
 

Overview of the Written Disaster Plan ........................................ 6
 

Drafting a Usable Plan ..................................................... 8
 

Chapter 2—Beginning the Disaster Planning Process . . . . . . . . . . . . . . . . . . . . . . . 9
 

Select a Disaster Planning Team Leader and Team .............................. 9
 

Obtain Support From the Organization’s Leadership ............................ 11
 

Review Requirements for Disaster Planning ................................... 11
 

Coordinate Planning With Others ........................................... 12
 

Educate the Community About Behavioral Health Services ...................... 21
 

Prepare a Hazard Identification and Risk Assessment ........................... 23
 

Specify Planning Objectives and Assumptions ................................. 24
 
Disaster Planning Handbook for Behavioral Health Treatment Programs

Chapter 3—Preparing for Disaster . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
 

Mitigate Risk ............................................................ 27
 

Negotiate Memoranda of Agreement ......................................... 28
 

Designate Personnel To Assume Command for Incident Response ................. 31
 

Prepare Clients for a Disaster............................................... 32
 

Obtain Client Locator Information ........................................... 34
 

Encourage Staff To Make Plans for Personal Preparedness....................... 35
 

Prepare Staff for Supporting Clients in Disaster................................ 35
 

Prepare To Connect Clients to Disaster Case Management ....................... 40
 

Ensure Counselor Access to Shelters ......................................... 40
 

Prepare for Financial Resiliency............................................. 41
 

Chapter 4—Continuity Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
 

Identify Essential Functions ................................................ 43
 

Identify Essential Staff .................................................... 43
 

Provide for Continuity of Leadership ......................................... 46
 

Arrange for Alternate Facilities ............................................. 47
 

Ensure Interoperable Communications ....................................... 48
 

Protect Vital Records and Databases ......................................... 51
 

Develop Resources To Manage Human Capital ................................ 53
 

Chapter 5—Management of Prescription Medications . . . . . . . . . . . . . . . . . . . . . . 57
 

Give Careful Oversight to Clients on Prescription Medications .................... 57
 

Help Clients Access Prescription Medications .................................. 57
 

Provide for Continued Methadone Dosing ..................................... 58
 

Prepare for Transfers of Patients ............................................ 60
 

Treat the Guest Patient on Methadone Maintenance Treatment................... 60
 

Handle an Influx of Patients With Opioid Dependence........................... 61
 

Address the Needs of Displaced Patients on Buprenorphine ...................... 61
 

iv 
Contents 

Refer or Treat Pain Patients, as Appropriate .................................. 63
 

Manage Supplies of Controlled Substances .................................... 63
 

Chapter 6—Planning Issues for Pandemic Influenza . . . . . . . . . . . . . . . . . . . . . . . 65
 

Potential Effects of Pandemic Influenza....................................... 65
 

Procedures To Reduce Influenza Transmission ................................. 66
 

Vaccines ................................................................ 68
 

Antiviral Medications ..................................................... 68
 

Hygiene Policies .......................................................... 69
 

Staffing Policies .......................................................... 69
 

Staff Attitudes ........................................................... 70
 

Planning Assumptions for Pandemic Influenza................................. 70
 

Drafting and Activating the Pandemic Plan ................................... 70
 

Chapter 7—Completing, Testing, Activating, and Deactivating the Plan . . . . . 73
 

Assemble the Plan ........................................................ 73
 

Distribute the Plan ....................................................... 74
 

Train and Test ........................................................... 74
 

Activate the Plan in Disaster ............................................... 77
 

Deactivate and Revise the Plan ............................................. 78
 

Coordinate With the Community in Recovery .................................. 79
 

Support Staff Members, Clients, and Community After the Disaster ............... 80
 

Continuously Revise and Update the Disaster Plan ............................. 81
 

Appendix A—Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
 

Appendix B—Worksheets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
 

Worksheet B1 Checklist for the Written Disaster Plan .......................... 90
 

Worksheet B2 Checklist for Disaster Planning ................................. 92
 

Worksheet B3 Checklist of State and Community Representatives and Groups ...... 93
 

Worksheet B4 Checklist of Disaster Planning Discussion Topics................... 94
 

v 
Disaster Planning Handbook for Behavioral Health Treatment Programs

Worksheet B5 Sheltering-in-Place Checklist................................... 96
 

Worksheet B6 Record of Memoranda of Agreement and Qualified Service

Organization Agreements ............................................... 97
 

Worksheet B7 Incident Command System Positions............................. 98
 

Worksheet B8 Identify Essential Functions.................................... 99
 

Worksheet B9 Identify Essential Staff Positions............................... 100
 

Worksheet B10 Essential Staff Roster ....................................... 101
 

Worksheet B11 Checklist for Continuity Planning ............................. 102
 

Worksheet B12 Requirements for Alternate Facilities .......................... 106
 

Worksheet B13 Alternate Facility Arrangements by Disaster Scenario ............ 107
 

Worksheet B14 Checklist for Relocation Planning ............................. 108
 

Worksheet B15 Checklist for Maintaining Communications With Essential

Groups. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
 

Worksheet B16 Checklist of Records and Databases To Ensure Interoperable

Communications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
 

Worksheet B17 Checklist for Protecting Records and Databases.................. 112
 

Worksheet B18 Checklist for Managing Human Capital ........................ 113
 

Worksheet B19 Checklist for Management of Prescribed Medications ............. 115
 

Worksheet B20 Disaster Plan Training and Testing Log ........................ 117
 

Appendix C—Abbreviations and Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
 

Appendix D—Disaster Planning Web Resources . . . . . . . . . . . . . . . . . . . . . . . . . . 121
 

Appendix E—WATrac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
 

Appendix F—Sample Memorandum of Agreement Between Opioid

Treatment Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
 

Appendix G—Editorial Board and Field Reviewers . . . . . . . . . . . . . . . . . . . . . . . 135
 

Appendix H—Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
 

vi 
Exhibits
 

Exhibit 2-1. Importance of Comprehensive Training for All Staff .................. 10
 

Exhibit 2-2. Mobilization of Behavioral Health Responders To Assist

Hurricane Evacuees.................................................... 12
 

Exhibit 2-3. Mobilization of Behavioral Health Responders To Assist

Earthquake Emergency Responders....................................... 12
 

Exhibit 2-4. Discriminatory Attitudes That Affected Care for People With

Mental Disorders ...................................................... 13
 

Exhibit 2-5. Discriminatory Attitudes That Affected Care for People With

Substance Use Disorders ................................................ 13
 

Exhibit 2-6. Networking To Improve Readiness for Disaster (Example 1) ........... 14
 

Exhibit 2-7. Networking To Improve Readiness for Disaster (Example 2) ........... 14
 

Exhibit 2-8. Program Use of SERG Grants .................................... 15
 

Exhibit 2-9. Distribution of Financial Aid in Louisiana After Hurricanes 

Katrina and Rita ...................................................... 15
 

Exhibit 2-10. Collaborative Planning by Healthcare Organizations ................ 17
 

Exhibit 2-11. Sample of a Disaster-Specific Prevention Message ................... 21
 

Exhibit 2-12. Example of Need To Coordinate With Voluntary Organizations ........ 22
 

Exhibit 2-13. Examples of Program Vulnerabilities and Strengths in a

Disaster.............................................................. 24
 

Exhibit 3-1. Welcome Bags and Personal Go Kits ............................... 28
 

Exhibit 3-2. Preparing for Power Failure...................................... 28
 

Exhibit 3-3. Examples of Disaster Mitigation Specific to a Behavioral Health

Treatment Program .................................................... 29
 

Exhibit 3-4. Negotiation for Assistance in Hurricane Season...................... 29
 

Exhibit 3-5. Negotiation for Mutual Aid Following a Major Snowfall ............... 29
 

Exhibit 3-6. Staff Issues To Consider in Mutual Aid Agreements .................. 30
 

Exhibit 3-7. Incident Command System....................................... 31
 

vii 
Disaster Planning Handbook for Behavioral Health Treatment Programs

viii 

Exhibit 3-8. Hypothetical Example of an ICS in Action .......................... 33
 

Exhibit 3-9. Psychological First Aid .......................................... 36
 

Exhibit 3-10. Challenges in Disaster Preparedness for Clients With Limited

English Proficiency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
 

Exhibit 4-1. Examples of Essential and Nonessential Functions ................... 44
 

Exhibit 4-2. Essential Operations Continuity During a Winter Storm

(Example 1). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
 

Exhibit 4-3. Essential Operations Continuity During a Winter Storm

(Example 2). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
 

Exhibit 4-4. Examples of Order of Succession at a Behavioral Health

Treatment Program .................................................... 47
 

Exhibit 4-5. Communication Tree............................................ 49
 

Exhibit 4-6. Priority Communications in an Emergency.......................... 50
 

Exhibit 4-7. Benefits of Electronic Health Records (Example 1).................... 52
 

Exhibit 4-8. Benefits of Electronic Health Records (Example 2).................... 52
 

Exhibit 4-9. Office for Civil Rights HIPAA Guidance Following Hurricane

Katrina .............................................................. 54
 

Exhibit 4-10. Building Staff Willingness To Respond in Disaster .................. 55
 

Exhibit 5-1. Distant Dispersal of OTP Patients................................. 60
 

Exhibit 5-2. An OTP’s Continuity Plan Executed Before Hurricane Hugo ........... 61
 

Exhibit 5-3. Guidance for Treating OTP Patients From Areas Affected by

Emergency Closure of Programs in the Event of a Disaster .................... 62
 

Exhibit 5-4. Guidance on Working With Patients Who Are Dependent on Opioids

 and Not Currently in Treatment ......................................... 63
 

Exhibit 5-5. Guidance on Working With Displaced Patients Treated by

Pain Clinics .......................................................... 63
 

Exhibit 6-1. Pregnant Women at Special Risk From Influenza .................... 66
 

Exhibit 6-2. Racial and Ethnic Minorities Disproportionately Affected by

Influenza............................................................. 66
 

Exhibit 6-3. Potential Effects of Influenza Pandemic on Behavioral Health 

Treatment Programs ................................................... 67
 

Exhibit 6-4. Pandemic Education Provided to Staff and Residential Patients ........ 69
 
Exhibits 

Exhibit 6-5. Examples of Pandemic Influenza Planning Assumptions............... 71
 

Exhibit 7-1. Tabletop Exercise for Opioid Treatment Programs.................... 75
 

Exhibit 7-2. Beneficial Networking at a Tabletop Exercise........................ 76
 

Exhibit 7-3. Effect of Timing Decisions on Staff ................................ 78
 

Exhibit 7-4. Examples of Recovery Steps ...................................... 79
 

ix 

Foreword
 

This Technical Assistance Publication (TAP), Disaster Planning Handbook for Behavioral 

Health Treatment Programs, provides guidance, and the underlying rationale, for management

and staff as they work together to create a comprehensive, scalable, and flexible disaster plan.

This resource can be used by management and the program’s disaster planning team as they

develop or update program processes, procedures, and written reference tools that support a

rapid and effective response when a disaster occurs. 

The TAP is intended to support the behavioral health treatment program at any stage of the

disaster planning process. A program in the beginning stages can use the TAP as a step-bystep guide, whereas the program with a well-developed plan can consult the TAP for ideas on

how to make improvements. In either case, disaster planning should be considered an evolving

process, and the plan itself should be viewed as a living document that must regularly be

reviewed, exercised, and updated. 

Guidance in this TAP aligns with Federal guidelines and current best practices in disaster

planning, including recommendations for protecting people’s health, which includes their

behavioral health, in the case of an emergency (U.S. Department of Health and Human

Services [HHS], 2009b, 2011a); for integrating behavioral health into the Nation’s overall

disaster preparedness, response, and recovery efforts (U.S. Department of Homeland

Security [DHS], 2011a); for planning across all threats and hazards (DHS, 2011b); and for the

participation of businesses and nonprofit organizations in the Nation’s preparedness (White

House, 2011). A panel of field reviewers, including behavioral health services providers with

experience in disaster preparedness and response, contributed and reviewed the content to

ensure that this document realistically reflects how behavioral health services programs can

respond to the challenge of disaster preparedness and response. 

This TAP advances the Substance Abuse and Mental Health Services Administration’s 

Strategic Initiatives, which provide a framework for addressing mental and substance use

disorders, building supportive communities, and improving the health of all Americans. An

overarching aim within these initiatives, “Achieving Excellence in Operations,” is advanced

when behavioral health treatment programs adopt best practices for disaster planning. A

second aim, “Improving the Nation’s Behavioral Health Care,” is advanced when Americans

are provided with essential behavioral health services during and following disaster. 

Pamela S . Hyde, J .D .

Administrator 

Substance Abuse and Mental Health Services Administration 

H . Westley Clark, M .D ., J .D ., 

M .P .H ., CAS, FASAM 

Director 

Center for Substance Abuse 

Treatment 

Substance Abuse and 

Mental Health Services 

Administration 

Frances M . Harding

Director 

Center for Substance Abuse 

Prevention 

Substance Abuse and 

Mental Health Services 

Administration 

Paolo del Vecchio, M .S .W . 

Director 

Center for Mental Health 

Services 

Substance Abuse and 

Mental Health Services 

Administration 

xi 

Introduction
 

This Technical Assistance Publication (TAP), Disaster Planning Handbook for Behavioral 

Health Treatment Programs, provides guidance for developing or improving the behavioral

health treatment program’s disaster plan. This document provides guidance for program

staff members on reducing their facility’s exposure to threats and hazards and retaining and

restoring the program’s capacity to function when a disaster does occur. A disaster plan is an

essential reference for program staff in a disaster situation—the planning process is the path

through which preparedness becomes possible. 

A disaster plan describes procedures for ensuring safety in a disaster, reducing the potential

for damage from a disaster, and maintaining or rapidly resuming essential services during

and after a disaster. The plan details procedures for the quick and efficient linking of clients

to other appropriate sources of care when the program itself cannot provide that care. It also

describes processes for the reengagement of clients once the program can again offer regular

services. 

The TAP addresses planning issues for staff at programs that provide treatment for mental

or substance use disorders, or both. This guidance addresses the planning needs specific to

programs that offer prevention services, outpatient or residential treatment, medically managed

detoxification, and medication-assisted treatment. The TAP also covers planning issues specific

to at-risk populations (e.g., children, senior citizens, pregnant women, those with chronic

medical disorders, those with pharmacological dependency). This guidance is to be considered

supplemental to, and is not in conflict with, requirements by healthcare licensing or accreditation

bodies (e.g., State licensing departments, CARF International, The Joint Commission) specific

to disaster planning for programs affiliated with them. All programs are required to be in

compliance with any regulatory requirements established by applicable Federal and State

regulations or laws. It is beyond the scope of this TAP to cover specific regulatory requirements.

Providers should obtain guidance directly from applicable regulatory entities. 

Audience for This TAP 

This TAP is intended for use by the disaster planning team of the behavioral health treatment

program and others responsible for management and oversight of preparedness. This team may

include program administrators responsible for developing and activating the organization’s

disaster plan, as well as senior staff members and clinicians who play leadership roles in

developing and testing the plan, coordinating staff training of the plan, and activating the plan

in an actual incident. The TAP also may be useful to executive directors and other members of

management in helping them understand their specific roles in the disaster planning process and

why their involvement and support are so important. State disaster behavioral health treatment

coordinators may find the TAP helpful in supporting their efforts to promote standardized

disaster planning, response, and recovery of mental health services and substance abuse

treatment programs in coordination with State, Federal, and jurisdictional plans. 

xiii 
Disaster Planning Handbook for Behavioral Health Treatment Programs 

Organization of This TAP 

Chapter 1 provides the rationale for the planning process. It also describes the development

of a written disaster plan. Creation of the written document helps focus the disaster planning

process, while the plan itself becomes a reference tool for use in any emerging disaster

situation. Once completed, the plan must be regularly updated to ensure that it remains

current and relevant. 

Chapters 2, 3, and 4 provide guidance for creating a disaster planning team and describe steps

to develop content for each part of the disaster plan. Chapter 5 provides guidance specifically

for management of prescription medications. Chapter 6 addresses the content that would

be included in a Pandemic Appendix to the disaster plan. Chapter 7 provides information

on completing the basic plan; testing, activating, deactivating, and updating the plan; and

coordinating with the community as it recovers from the disaster. 

Worksheets (located in Appendix B) are tied to the chapter guidance. The disaster planning team

can refer to these worksheets to identify steps and document actions and arrangements. Some

worksheets are checklists to guide the planning process whereas others, when completed, can

become part of the written plan. Appendix D includes useful disaster planning Web resources. 

Behavioral Health Terms 

A few key terms from the behavioral health field are defined here, for clarity. 

behavioral health—Behavioral health is used in this TAP to refer to a 

state of mental/emotional being and/or choices and actions that affect wellness. Behavioral health problems 

include substance abuse or misuse, alcohol and drug addiction, serious psychological distress, suicide, and 

mental and substance use disorders. This includes a range of problems from unhealthy stress to diagnosable 

and treatable diseases like serious mental illnesses and substance use disorders, which are often chronic 

in nature but that people can and do recover from. The term is also used to describe the service systems 

encompassing the promotion of emotional health, the prevention of mental and substance use disorders, 

substance use, and related problems, treatments and services for mental and substance use disorders, and 

recovery support. (Substance Abuse and Mental Health Services Administration, 2011a, p. 1, footnote i) 

client and patient—Client is used inclusively to refer to any recipient of behavioral health

treatment services. Patient is used only when the reference is specifically to an individual in

a medically directed residential treatment program, undergoing medical detoxification, or

receiving medication-assisted treatment (e.g., methadone maintenance treatment). 

co-occurring—The term refers to co-occurring mental disorder and substance use disorder. A

client with co-occurring disorders may have one or more of both types of disorders. 

program—Program is frequently used in this TAP in place of the full phrase behavioral health 

treatment program, meaning a program providing services for the treatment or prevention

of mental or substance use disorders, or both. To avoid lengthy phrasing, the word program

is also used to represent the people who work in the program and who develop and execute

disaster planning activities (e.g., “The program has an obligation to prepare for potential

disasters because . . . .”). The TAP provides guidance as if a program creates only one disaster

plan. However, the program with multiple facilities (i.e., buildings or sites) will need to tailor

its plan for each location. 

xiv 
Introduction 

Disaster Terms 

Below are several disaster terms related to this TAP. Unless otherwise indicated, the 

definitions provided are verbatim from the cited source materials. 

disaster—An occurrence of a natural catastrophe, technological accident, or human-caused

event that has resulted in severe property damage, deaths, and/or multiple injuries. (Federal

Emergency Management Agency [FEMA], 2010a, p. B-3) 

emergency—Any incident, whether natural or human-caused, that requires responsive

action to protect life or property. Under the Robert T. Stafford Disaster Relief and Emergency

Assistance Act, an emergency means any occasion or instance for which, in the determination

of the President, Federal assistance is needed to supplement State and local efforts and

capabilities to save lives and to protect property and public health and safety, or to lessen or

avert the threat of a catastrophe in any part of the United States. (FEMA, ca. 2011) 

Note: The words disaster and emergency are closely related and often used synonymously.

However, in the healthcare field, emergency frequently refers to medical or psychiatric

incidents involving an individual (e.g., a patient having seizures or hallucinations). To avoid

confusion, in this TAP the word disaster is used when referring to any incident that has the

potential to adversely affect a facility’s ability to operate and provide services to clients, even

if the incident is emerging or possibly small in scope. Similarly, in this TAP the term disaster 

planning is often used even though FEMA and many jurisdictions use terms such as emergency 

planning and emergency operations planning. 

emergency management/response personnel—Includes Federal, State, territorial, tribal, 

substate, regional, and local governments, nongovernmental organizations (NGOs), private

sector organizations; critical infrastructure owners and operators, and all other organizations

and individuals who assume an emergency management role. Also known as emergency or first

responder. (FEMA, ca. 2011) 

hazard—Something that is potentially dangerous or harmful, often the root cause of an

unwanted outcome. (FEMA, ca. 2011) 

hazard identification and risk assessment (HIRA)—A process to identify hazards and

associated risk to persons, property, and structures and to improve protection from natural

and human-caused hazards. HIRA serves as a foundation for planning, resource management,

capability development, public education, and training and exercises. (FEMA, 2008) Another

term for this assessment is threat and hazard identification and risk assessment (THIRA). 

incident—An occurrence, natural or human-caused, that requires a response to protect life or

property. Incidents can, for example, include major disasters, emergencies, terrorist attacks,

terrorist threats, civil unrest, wildland and urban fires, floods, hazardous materials spills,

nuclear accidents, aircraft accidents, earthquakes, hurricanes, tornadoes, tropical storms,

tsunamis, war-related disasters, public health and medical emergencies, and other occurrences

requiring an emergency response. (FEMA, ca. 2011) 

mitigation—Those capabilities necessary to reduce loss of life and property by lessening the

impact of disasters. Mitigation capabilities include, but are not limited to, community-wide risk

reduction projects; efforts to improve the resilience of critical infrastructure and key resource

lifelines; risk reduction for specific vulnerabilities from natural hazards or acts of terrorism;

and initiatives to reduce future risks after a disaster has occurred. (White House, 2011) 

xv 
Disaster Planning Handbook for Behavioral Health Treatment Programs 

preparedness—A continuous cycle of planning, organizing, training, equipping, exercising,

evaluating, and taking corrective action in an effort to ensure effective coordination during

incident response. Within the National Incident Management System (NIMS), preparedness

focuses on the following elements: planning, procedures and protocols, training and exercises,

personnel qualification and certification, and equipment certification. Examples: Conducting

drills, preparing homework packages to allow continuity of learning if school closures are

necessary, etc. (FEMA, ca. 2011) 

prevention—Actions to avoid an incident or to intervene to stop an incident from occurring.

Prevention involves actions to protect lives and property. Examples include: Cyberbullying

prevention, pandemic influenza sanitation measures, building access control procedures,

security systems and cameras, etc. (FEMA, ca. 2011) 

Note: When Institute of Medicine classifications for prevention are applied to behavioral health

(e.g., prevention of mental or substance use disorders), the term prevention can carry the

specific meaning of universal prevention (strategies targeted at the entire population); selective 

prevention (strategies targeted at subsets of the total population considered to be at-risk);

and indicated prevention (strategies targeted at individuals who show signs and symptoms

of the disorder) (paraphrased from National Institute on Drug Abuse, 1997). In this TAP, the

intended meaning of prevention (disaster or behavioral health related) can be inferred from the 

context. 

reconstitution—The resumption of non-emergency operations at a primary facility following

emergency operations at an alternate facility. (FEMA, 2004) 

recovery—Those capabilities necessary to assist communities affected by an incident to

recover effectively, including, but not limited to, rebuilding infrastructure systems; providing

adequate interim and long-term housing for survivors; restoring health, social, and community

services; promoting economic development; and restoring natural and cultural resources.

(White House, 2011) 

Note: In the behavioral health treatment field, recovery means the remission of symptoms of

mental or substance use disorders, or both. In this TAP, recovery is used as both a behavioral 

health term and as a disaster-related term. The meaning in each instance should be clear from

the text. 

response—Those capabilities necessary to save lives, protect property and the environment,

and meet basic human needs after an incident has occurred. (White House, 2011) 

xvi 
Chapter 1—Rationale and Process 

for Planning 

In This Chapter 

•	 Essential Partners in 

National Preparedness 

•	 Providers of Essential 

Services 

•	 Partners in Community

Preparedness 

•	 Mandates for Disaster 

Planning 

•	 All-Hazards Planning 

•	 The Planning Process 

•	 Continuity Planning 

•	 Overview of the Written 

Disaster Plan 

•	 Drafting a Usable Plan 

Worksheet (see Appendix B) 

•	 B1 Checklist for the Written 

Disaster Plan 

Disaster planning can save lives, minimize injury and

emotional trauma, protect property and operational

capability, and prevent or reduce interruptions in

treatment. For all of these reasons, the behavioral 

health treatment program should coordinate with

its community long before disaster strikes, to

plan and prepare for a rapid, effective response to

disaster. Program staff also need to document those

preparations in a format that is readily understood

and easy to navigate so that personnel can refer to

the plan under time-sensitive conditions. This chapter

covers the reasons for disaster planning, explains

the basis for the kind of planning proposed in this

Technical Assistance Publication (TAP), and provides

an overview of the written disaster plan. 

Essential Partners in National 

Preparedness 

Our Nation faces a wide range of threats and hazards, 

including acts of terrorism, cyber attacks, pandemics, 

and catastrophic natural disasters. Communities can 

address the risks these threats and hazards pose by 

working together using a systematic approach that builds 

on proven preparedness activities. (U.S. Department of 

Homeland Security [DHS], 2011b, p. 1) 

National preparedness is the shared responsibility of our 

whole community. Every member contributes, including 

individuals, communities, the private and nonprofit sectors, 

faith-based organizations, and Federal, state, and local 

governments. (DHS, 2011c, p. 1) 

As suggested by these quotations from national

preparedness documents, disaster readiness

is not accomplished ad hoc or in isolation. It is

done systematically and in coordination with all

stakeholders. To the extent that behavioral health 

treatment programs exist in the community and serve 

the community, they are essential partners in national

preparedness. 

1 
Disaster Planning Handbook for Behavioral Health Treatment Programs

Providers of Essential Services 

The behavioral health treatment program has

a special obligation to prepare for disasters

because it provides essential services. Disaster

services in support of behavioral health are

named in Emergency Support Function (ESF)

#8 (Public Health and Medical Services) of the 

National Response Framework (DHS, 2013)

and in a Recovery Support Function (Health

and Social Services) of the National Disaster 

Recovery Framework (DHS, 2011a).* 

*

The Federal agencies that coordinate these Federal preparedness plans are the Office of the Assistant Secretary 

for Preparedness and Response, U.S. Department of Health and Human Services (ESF #8), and National 

Disaster Recovery Planning Division, Federal Emergency Management Agency, DHS (National Disaster Recovery 

Framework). The behavioral health treatment program typically does not work directly with these Federal agencies

but rather through local disaster planning leadership. See Coordinate Planning With Others, in Chapter 2. 

By their nature, disasters have an impact on

behavioral health: 

Most people who experience a disaster, whether 

as a victim or responder, will have some type 

of psychological, physical, cognitive, and/or 

emotional response to the event. Most reactions 

are normal responses to severely abnormal 

circumstances. (American Medical Association, 

2005, p. 2) 

Thus, there can be significant demand for

behavioral health services as a result of a 

disaster and significant consequences if a

program suddenly closes or is forced to reduce

services. 

Disaster planning can prepare the program

for continuing to provide behavioral health

services to its existing clientele. Otherwise: 

• Clients in recovery may relapse to

substance abuse, or their psychiatric

symptoms may recur, at the very time they

must cope with the uncertainties, traumas,

and losses caused by the disaster. 

• Patients receiving medically managed

detoxification for alcohol and drug

abuse are at risk of serious medical and 

psychological complications if the process

is interrupted. 

• Patients in residential treatment programs

that have closed may have no other 

safe place to go to complete their initial

recovery goals. 

• Patients on psychotropic medications (e.g.,

antipsychotic medications, anti-anxiety

medications) who obtain their medications

at the program, or who are assisted by staff

in taking their medications regularly, are

at risk of serious withdrawal symptoms

(e.g., seizures, delirium tremens) if the

medications are stopped abruptly. Similarly,

patients receiving methadone treatment for

opioid dependence may develop withdrawal

symptoms (e.g., tremors, hallucinations) if

their treatments are interrupted. 

• At-risk populations (e.g., children, senior

citizens, pregnant women, those with

chronic medical disorders, those with 

pharmacological dependencies) may face

unique hardships and challenges if suddenly

deprived of their program’s support. 

Just as important, disaster planning can

prepare the program for providing behavioral

health services to new clients: 

• In the weeks and months following a

disaster, the program may experience

a surge in demand for services from

individuals for whom the disaster has 

created a need for assessment or treatment 

services and from clients previously

treated at other programs who have been

displaced from their local community. 

• A program that has been spared by the

disaster may be called on to provide aid to

other programs (e.g., treating guest clients,

sharing medications, lending staff members)

or to other community organizations (e.g.,

sharing resources, reassigning staff). 

• Staff members may be asked, based on

their training, to provide emergency

community-based behavioral health

services (e.g., crisis counseling or

intervention, psychological first aid,

assessments and referrals). 

2 
Chapter 1―Rationale and Process for Planning 

Partners in Community 

Preparedness 

The behavioral health treatment program’s

disaster planning contributes to the overall

preparedness of the community. Proper

planning helps prepare for potential rapid

surges of vulnerable populations needing

behavioral health services and for the rapid

transition of services to other locations when 

the program and community are overwhelmed. 

Such planning is critical; it has been

estimated that, after a disaster, a community’s

healthcare facilities may experience a surge

for behavioral health services that could range

from 4 to 50 times higher than the surge for

medical care (Meredith, Zazzali, Shields,

Eisenman, & Alsabagh, 2010). A variety of

factors or “triggers” are theorized to contribute

to elevated demand for behavioral health 

services in a disaster situation. These include 

restricted movement (e.g., quarantine, shelter

stays, evacuation); limited resources (including

denial of, limitation of, or suspended

access to care); exposure to trauma (both

direct and indirect, such as through media

exposure); limited information (including

insufficient or inaccurate information or 

rumors); and perceived personal or family

risk. Representatives of behavioral health

treatment programs can work with community

planners to put into place the structures

and processes that support people’s adaptive

and appropriate responses to these triggers

(Meredith, Eisenman et al., 2011). 

Another significant contribution the treatment

program can make as it participates in its

community’s disaster readiness is to advocate

for the needs of people with behavioral health

disorders, including people with chronic

mental disorders, people with new-onset

disorders triggered by the disaster, and

people who are physiologically dependent

on medications or illicit drugs (Rabins,

Kass, Rutkow, Vernick, & Hodge Jr., 2011).

Programs also can advocate for training

of emergency responders so that they can

recognize signs of severe psychological

trauma, cognitive incapacity, or a substance 

use disorder and know how to route people

displaying such signs to appropriate services.

This would better ensure that responder

interactions with affected individuals are 

managed appropriately, that the identified

individuals receive the behavioral health 

services and protections they require, and that

their due process rights are protected. 

Mandates for Disaster Planning 

Disaster planning is not just prudent and

practical, it is required: 

• Most States require a disaster plan for

program licensure. 

• The Joint Commission and CARF 

International each require a disaster plan

for accreditation. 

• To receive Medicaid reimbursement, 

programs offering mental or substance

use disorder treatment services must be in 

full compliance with licensure regulations,

including those pertaining to disaster

planning. 

• Disaster planning is a requirement for

opioid treatment program certification. 

• Behavioral health treatment programs

that are part of healthcare coalitions

receiving funds through the Hospital

Preparedness Program are obligated to

plan for response to common medical

disasters (Office of the Assistant Secretary

for Preparedness and Response, 2012). 

•	 Federally qualified health center

programs, rural health clinics, and other

primary care safety net providers are

obliged, as extensions of the Federal

Government, to conduct disaster planning. 

Ideally, the disaster planning process helps

the program identify and obtain the resources

and training it needs to forge an effective

response to a range of potential calamities.

As staff members work together across

departments to create and test the plan, they

build relationships that will be important

when they must work together under the 

3 
Disaster Planning Handbook for Behavioral Health Treatment Programs

intense conditions of a real disaster. The 

planning process also provides program

staff with opportunities to meet and build

relationships with other professionals from

the community who will be key partners in

the event of a disaster. As a result, the entire 

infrastructure of the program is strengthened

and more adequately prepared for response to

unusual incidents of any kind and scope. 

All-Hazards Planning 

This TAP describes an all-hazards approach

to planning. All-hazards planning means that 

planners prepare for response to a full range

of threats and dangers but with a focus on

the specific incidents most likely to occur in

their area (Federal Emergency Management

Agency [FEMA], 2010a). This kind of planning

begins with an extensive risk assessment

based on probabilities of anticipated events

occurring in the program’s or facility’s specific

locality. Based on the risks identified, a

program addresses the capabilities needed to

respond. For example, the risk assessment

may document that the program is situated

in an area susceptible to flooding. The

program begins with response plans for

flooding (e.g., taking preventive actions to

protect the facility from flooding, developing

an evacuation plan, creating plans for clients

and patients to be treated outside the flood

area, ensuring that records are backed up in

another location). These plans can be adapted

when responding to other types of disasters. 

The Planning Process 

The planning process described in this TAP

aligns with that recommended for entities

such as State, territorial, Tribal, and local 

governments; planners in other disciplines,

organizations, and the private sector (FEMA,

2010a); and courts (National Center for

State Courts, 2007). This process is based

on Federal policies for disaster planning,

including the National Preparedness System,

the National Disaster Recovery Framework

(NDRF), and the National Incident

Management System (NIMS). 

The National Preparedness System

presents a collaborative, whole-community

approach for building a secure and resilient

Nation that can confront any threat or

hazard. Components include: identifying

and assessing risk, estimating the level of

capabilities needed to address those risks,

building or sustaining the required levels

of capability, developing and implementing

plans to deliver those capabilities, validating

and monitoring progress, and reviewing

and updating efforts to promote continuous

improvement (DHS, 2011b). 

NDRF is a statement of the principles

guiding effective recovery from large-scale

or catastrophic disasters. Its objective is to

guide a unified and collaborative response

for restoring, redeveloping, and revitalizing

communities (DHS, 2011a). 

NIMS identifies the terms, protocols,

procedures, and standards that should

be used so that disaster response can be

effectively coordinated at the local, regional,

State, and Federal levels. NIMS provides all

partners involved in a disaster response a

common language and a standardized way

to communicate about their responsibilities,

activities, and functions. A NIMS-modeled 

disaster plan is flexible: it can be scaled up

or down, depending on the size, scope, and

complexity of the disaster, and it can be

readily integrated into the plans of other

responding organizations (DHS, 2008). 

A basic premise underlying NIMS is that

incidents typically are managed at the local

level first. In the vast majority of incidents,

local resources provide the first line of

emergency management and incident response.

If additional or specialized resources or

capabilities are needed, State governors may

request Federal assistance. However, local

jurisdictions retain command, control, and

authority over response activities in their areas. 

Behavioral health treatment programs—

whether public, private, or nonprofit—should

develop disaster plans that comply with

NIMS (FEMA, 2006). A NIMS-compliant 

4 
Chapter 1―Rationale and Process for Planning

program agrees to manage disaster incidents

using the Incident Command System

(see Chapter 3) and to coordinate with

other responders for decisionmaking and

public communication. The program also

agrees to train key staff members in NIMS

preparedness, participate in internal and

external training exercises, and incorporate

NIMS concepts into its disaster plan. 

The behavioral health treatment program

should use the NIMS approach to disaster

planning and training for the following 

reasons: 

• NIMS was developed based on best

practices and has been extensively tested

throughout the country, proving its

effectiveness in providing a framework for

a coordinated disaster response. 

• Almost all government and community

training on disaster response is based on

NIMS. 

• Staff members who understand NIMS and 

prepare to respond using NIMS protocols

will more readily fit into their community’s

response activities. The program,

therefore, will be in a better position to get

and to give help in a disaster. 

• Adhering to NIMS enables the program to

better use incoming resources, including

deployed staff and volunteers. 

• Program staff members who may be called

on to serve as part of an external disaster

response (e.g., as members of the State’s

behavioral health disaster response team)

must be credentialed in and operate within

the NIMS structure. 

Appendix D, Disaster Planning Web Resources, 

provides links to various Federal planning 

guidelines. 

Continuity Planning 

Behavioral health programs need to plan not

only for responding to a disaster as it hits

(disaster planning), but also for continuing

essential operations under a broad range of

circumstances that could follow a disaster 

(continuity planning). Thus, a vital part of

the program’s overall disaster plan is its

business continuity plan, commonly called its 

continuity of operations plan, or COOP plan. 

The latter term originally referred to planning

by government entities, but it has been

adopted by businesses and organizations. 

Continuity planning requires a program’s

personnel to consider the threats that

could adversely affect essential functions;

determine the personnel, vital information

(e.g., patient medical records including

prescription records), and other resources

required to continue those essential functions;

develop plans for providing essential

functions onsite or at alternate locations if 

needed; make advance arrangements for

obtaining the resources necessary to support

essential functions throughout the disaster

and recovery phases; and plan for the safety

of all personnel during these periods. The

continuity plan can be scaled up or down as

needed to accommodate the quantity and

variety of clients who need services. Elements

of the continuity plan may be activated either

in conjunction with a disaster declaration by

a government official or independent of such

a level of response. 

Examples of scenarios in which a program

would implement a continuity plan include

the following: 

• When the program must cease provision

of nonessential services due to a sudden 

reduction in resources, infrastructure, 

or available personnel (e.g., during a

pandemic) 

• When the program cannot provide

essential services to clients at its original

location (e.g., when the facility is damaged

due to a fire or access is blocked due to a 

chemical spill or a blizzard) 

5 
Disaster Planning Handbook for Behavioral Health Treatment Programs

• When evacuation to another geographic

area is recommended or mandated (e.g.,

because of an advancing hurricane) 

• When staff and resources are diverted 

to provide urgent care to community

members in distress 

Continuity planning helps the program

prepare for meeting the needs of existing

clientele and for a possible increase in

demand that can occur after a disaster, either 

in the immediate aftermath or in the months 

that follow. Increases may occur both in

the number of individuals needing services

and in the severity of clients’ addictions

and psychiatric conditions. Characteristics

(e.g., age, gender, culture, English-language

proficiency, home location, behavioral health

and medical conditions) of guest clients or

new clients after a disaster may differ from

those of the program’s preexisting clientele.

The program may have to adapt quickly to

accommodate a variety of clients and their

needs, such as: 

• Current clients who are facing extra

stressors arising from the disaster

and need extra counseling, psychiatric

monitoring, or other support to maintain

and continue recovery from a behavioral

health disorder. 

• Guest clients from other treatment 

programs or under physician care who

have been displaced by the disaster and

who come to the program for short- or longterm assistance. 

• Individuals who completed treatment or

discontinued services prior to a disaster

but whose recoveries are now threatened 

as a result of the event. 

• Individuals with an ongoing, untreated

mental or substance use disorder (or both)

who need treatment to prevent further

deterioration or to prevent an escalation

of dangerous medical or psychological 

symptoms. 

• Family members of clients who need

assistance for their loved ones, or for 

themselves, to alleviate concerns. 

These individuals may benefit from an

established or temporary telephone hotline

answered by trained crisis intervention

and referral staff (possibly nonclinicians or

prevention staff). 

• Patients who have been stabilized for long

periods on antidepressants, antipsychotics,

or medications for opioid addiction who

are not able to obtain prescription refills

and are in danger of sudden medication

withdrawal or relapse to psychiatric or

addiction symptoms. These patients may

need evaluation and referral to resources. 

• Patients on opioid medication for pain

who cannot obtain services from their 

physician, are facing or experiencing

withdrawal, and request help from the

treatment program. These patients may

need referral to pain specialists. 

Overview of the Written 

Disaster Plan 

The written disaster plan needs to be flexible

in its application and comprehensive, but

not overwhelming, in scope. Ideally, it is

organized so that it can be quickly referenced

in a disaster situation. 

The components of a disaster plan are briefly

described in the following section. More detail

is provided in Chapters 2, 3, and 4, which

outline the processes by which the disaster

planning team gathers information, makes

planning decisions, and compiles information

into a written disaster plan. Worksheet 

B1 (Appendix B) can be used as a checklist

for assembling plan components into one

document. 

The Basic Plan 

The introductory section of the basic 

plan includes a statement of purpose and

objectives and other summary information,

including the scope of the plan, the

populations served by the program, and the

program’s essential functions. Also included

in the basic plan are a situation overview 

6 
7 

Chapter 1―Rationale and Process for Planning

(e.g., the hazards the program is most likely

to face, the program’s response capabilities,

the steps that have been taken to reduce risk)

and a section on planning assumptions. 

Following the introductory section, the basic

plan contains a statement about the concept 

of operations (i.e., the organization’s overall

approach in responding to disaster). This

statement should address procedures for

activating and deactivating the plan and the

general sequence of actions to be taken—by

whom—before, during, and after an incident.

The statement should also provide the

following: a list of the personnel positions

authorized to make requests for outside aid

or assistance, the conditions under which 

to request aid, the procedures for managing

requests to give aid, and a list of the

resources that can be used in those efforts. 

Methods and schedules for updating the plan,

communicating changes to staff, and training

staff on the plan should also be included in

the concept of operations. 

Functional Annexes 

A set of instructions for a specific hazard

response procedure is referred to as a 

functional annex. Each annex is separately

attached to the disaster plan to avoid

cluttering the basic plan with too much

detail. This structure also makes it easier to 

update and revise individual components of

the disaster plan as needed. 

A functional annex can be as short as a 

paragraph or as long as several pages.

Examples of functional annex topics include

procedures for the emergency phase, such

as facility evacuation, sheltering-in-place,

and handling the media. The continuity

plan is a functional annex that is often

the largest section of the overall disaster

plan (development of this functional annex

is addressed in Chapter 4). Decisions on

whether to include procedural instructions

in the basic plan or in a separate functional

annex depend on the size and complexity of

the program and the level of sophistication

in planning that the program has attained. 

A functional annex should not repeat

information in the basic plan. It should

add only those details that are necessary to

perform the procedure. 

Hazard-Specific Appendices 

In its initial work, the disaster planning team

conducts or gathers, from partner agencies in

the community, a hazard identification and 

risk assessment (HIRA; see Chapter 2). The

HIRA identifies the specific types of threats

or risks most likely to occur and the potential

impact of each type on the program. In

response to each identified hazard, threat, or

incident, the disaster planning team develops

response procedures based on industry

safety standards and regulations (e.g.,

those issued by the Occupational Safety and

Health Administration). These procedures

are attached as a hazard-specific appendix

to the basic plan. For example, if the

HIRA identifies hurricanes and hazardous 

materials spills as possible hazards to the

program, the planning team would develop

two appendices, one for each hazard. 

A hazard-specific appendix should not repeat

information that is in either the basic plan

or any functional annex, both of which

provide instruction applicable to all hazards.

It should add only those details that are

specific to the hazard being addressed. If the

details are few, hazard-specific information

can be presented in a few sentences at the

end of each functional annex. For example, a

functional annex of instructions for backing

up and saving computer data may include

separate procedures for tornado scenarios,

in which there is little time to act, and for 

hurricane scenarios, for which more warning

time is available. 

Alternatively, an appendix can be added that

contains all special instructions relative to a

particular type of hazard, threat, or incident.

Each specific appendix is inserted after

the basic plan and the functional annexes.

(See Chapter 6 for guidance on preparing a

Pandemic Appendix.) The disaster planning

team chooses the format for its hazard­
Disaster Planning Handbook for Behavioral Health Treatment Programs

specific information that makes the most

sense for the personnel who will be using the

disaster plan when an incident occurs. 

Implementing Instructions 

Material that helps staff members perform

essential tasks during a disaster—referred to 

as implementing instructions—are attached 

to the back of the basic plan, with copies

distributed to pertinent personnel. Typically,

the material includes the program’s safetyrelated policies and procedures; these should

be periodically reviewed and updated with

a schedule in place to communicate to staff

about changes and provide recurrent training. 

Implementing instructions also can include

job-related aids that staff can use to perform

disaster response tasks (e.g., checklists,

worksheets, laminated wallet cards or sheets, 

scripts that staff can use when providing

disaster-related information to consumers 

and the public). 

Other materials that can be attached to the 

plan include Memoranda of Agreement (see

Chapter 3 and Appendix F), building floor

plans, community maps, and one or more of

the completed worksheets from Appendix B

such as Worksheet B7, Incident Command 

System Positions. The types of implementing

instructions that can be attached to the basic 

plan are discussed in subsequent chapters

and are included in the checklist found in 

Worksheet B1, in Appendix B. 

Drafting a Usable Plan 

A key objective is to organize the material

so that information can be referenced 

immediately when needed and actions 

can be taken quickly. The plan is a guide,

not a script. It is a useful tool for training

staff, evaluating exercises and drills, and

sharing with other community partners who

participate in disaster response. In a real

disaster, the people who execute the plan will

have to adjust their actions as the situation

dictates and as facts replace planning

assumptions. 

Drafters of the plan are encouraged to

aim for a simple and flexible plan and to

avoid creating a document that attempts

to cover all possible contingencies; that

goal is impossible, and the result will be an

unwieldy, difficult-to-navigate document. The

plan should be written in easy-to-understand

language that makes use of agreed-on and

defined terms and that provides concrete,

actionable guidance (FEMA, 2010a). 

The plan can be maintained in electronic

form, so long as it is accessible to all key

personnel. Paper backup copies should also be 

kept in case of a situation in which electrical

power or computer systems are down. Paper

versions of the plan must be dated and old

versions replaced and destroyed to eliminate

confusion. Electronic version control is also 

important; it can be helpful to track changes

on a separate grid sheet attached to the

document, to replace the date as changes

are made, and to archive old versions so 

that personnel access only the most current

version. Communication to staff of any

updates should be part of the program’s

standard safety practice. 

8 
Chapter 2—Beginning the Disaster 


Planning Process
 

In This Chapter 

•	 Select a Disaster Planning

Team Leader and Team 

•	 Obtain Support From the

Organization’s Leadership 

•	 Review Requirements for

Disaster Planning 

•	 Coordinate Planning With

Others 

•	 Educate the Community

About Behavioral Health 

Services 

•	 Prepare a Hazard

Identification and Risk 

Assessment 

•	 Specify Planning Objectives

and Assumptions 

Worksheets (see Appendix B) 

•	 B2 Checklist for Disaster 

Planning 

•	 B3 Checklist of State and 

Community Representatives

and Groups 

•	 B4 Checklist of Disaster 

Planning Discussion Topics 

This chapter provides guidance on forming a disaster

planning team, obtaining clarity on the scope and

responsibilities for the team, and gathering initial

data. A key step in this process is integrating with

the other entities in the community whose efforts,

when disaster occurs, will be orchestrated through

an Incident Command System (Chapter 3 addresses

the Incident Command System). Planning activities

recommended in this chapter are listed in checklist

form in Worksheet B2 (in Appendix B). 

Select a Disaster Planning Team Leader and 

Team 

Disaster planning is a cycle that begins with planning

and moves through various stages of training,

testing, evaluating, revising, and further planning

as circumstances evolve. This cyclical process helps a

program create a suitable plan for its facility that can

be effectively implemented by staff and kept current.

Because of the continuous nature of this process,

the program’s disaster planning team needs to be

a permanent part of the organization. Its ongoing

responsibilities can include making revisions to the

plan (based on insights gained through testing or

actual disaster response, or because the program has

changed), monitoring the plan as a whole to ensure

that it remains coherent, and coordinating testing and

training based on the plan. 

The program with a small staff may include every

employee on its disaster planning team, whereas a

large program can assemble a team representing

various departments or functions of the organization.

The program with several locations will generate one

disaster plan, but each separate facility (or its function)

needs to be represented on the disaster planning team

to ensure that its particular needs, vulnerabilities,

and client population are reflected in the plan. Sitespecific safety personnel or leadership would be logical

members of the disaster planning team. 

As another option, a program’s existing standing

committee (e.g., safety committee) can double as 

9 
Disaster Planning Handbook for Behavioral Health Treatment Programs

10 

the disaster planning team. Typically,

this committee includes individuals or 

departments responsible for safety (e.g., fire

drill coordination, building and parking lot

safety, computer systems security). 

Members of the planning team are described

in the following sections. 

Team Leader 

The leader of the disaster planning team may

hold any of several titles (e.g., emergency

manager, emergency coordinator, business

continuity manager, continuity of operations

coordinator). If the program is small, the

program’s executive director or facility

administrator may serve in this position.

Alternatively, the executive director may

delegate responsibility for managing the

plan to someone else who has leadership

and organizational skills, is familiar with

all aspects of the organization, and has

experience with disaster planning or has a

willingness to learn. 

Typically, the leader convenes and conducts

team meetings, ensures that team members

receive the training they need to contribute

effectively to disaster planning, and works

with team members to gather information.

The leader is responsible for ensuring that

the plan is developed, tested, and maintained

and that the organization’s leadership and

departments are informed of the disaster plan 

and their roles in its implementation (Exhibit

2-1). The team leader also typically serves as

the organization’s representative at disaster

planning meetings in the community and is

the liaison for the program as it engages in

local or regional disaster planning exercises. 

The person who leads the disaster planning

team is not necessarily the person who will

be assigned to lead the organization during

its response to a disaster. The latter role is

called Incident Commander, and the position

and its duties are described in Chapter 3. 

Exhibit 2-1. Importance of Comprehensive Training for All Staff 

During a recent response to a highly unexpected earthquake at our program in Virginia, a “debrief” 

was scheduled with representatives from both administrative and clinical staff to discuss response to 

the event. During that debrief, what became clear was that the administrative staff had not been fully 

informed on the particulars of who would take charge of various disaster-related responsibilities or 

specific disaster roles. Prior to this event, the assumption was that only key staff needed full training on 

all aspects of the disaster plan. This proved to be a false assumption. Although role-specific training is 

important, there is a danger that it may become too targeted and not allow for a big-picture view of all 

parts and participant roles in a response. The debrief resulted in changes to training requirements and 

a new appreciation for providing all staff with more comprehensive training so that the disaster-related 

roles of everyone in the organization are clear. 

Source: Elizabeth Ludeman-Hopkins, personal communication, January 22, 2012. 

Representatives From Across Departments 

All departments of the facility or

organization, especially those providing

essential functions, should be represented on

the disaster planning team. Members should

include both clinical and nonclinical staff, 

especially those involved in residential or

round-the-clock services, and administrative 

staff and management. Everyone has a role

in disaster preparedness and response. 

Staff members who do not serve on the 

planning team will become involved in later

stages of planning, when sections of the draft

plan are circulated for comment and when

the plan is tested in exercises and drills.

Feedback from these staff members can be 

used to improve the plan. This testing process

is described in Chapter 7. 
11 

Chapter 2—Beginning the Disaster Planning Process

It is important to involve all staff members

either on the disaster planning team or in

support of the work of the team because: 

• Broad staff involvement ensures that all 

critical operations are addressed in the plan. 

• Ongoing input from all staff members can

keep the disaster planning team aware of

changes in equipment or procedures that

may affect disaster operations. 

• Staff members are more likely to follow a

plan they have helped develop. 

• Staff members already familiar with

their roles are less likely to need lastminute training when the plan must be

implemented. 

• Staff members familiar with the disaster 

response plan may be less likely to

experience panic, fear, and anxiety when

an incident occurs. 

• Staff members who are engaged in

developing the plan may be more likely

to recognize the importance of creating

emergency plans for their homes. During

a disaster, having home plans can reduce

staff members’ anxiety over their families’

safety and enable those staff members

to be physically and mentally present for

their job functions. 

Obtain Support From the 

Organization’s Leadership 

As with any kind of planning, disaster planning

has costs associated with it. Management

shows its support by considering the budget

impact of the planning process, as well as

disaster preparation, response, and recovery

activities. To fully prepare the organization

for continuity of operations, management may

need to develop a multiyear budget plan. 

An organization’s leader contributes to the

success of disaster planning by providing

the planning team with specific expectations

regarding the scope of its mission and

encouraging everyone in the organization to

cooperate with the team’s work. Typically, the 

organization’s leader serves in direct authority

over the team and maintains a direct line 

of communication with the team leader to 

get regular updates related to planning and

response activities. The leader lends credibility

to the disaster planning by participating on

the team as other duties permit. 

Other ways that the program’s leader

promotes the importance of this project

include appointing the members of the team

(rather than delegating this task), ensuring

that all relevant departments are included

on the team, and allocating resources from

the organization to the team (e.g., space to

meet; compensated time for team members

to obtain training, attend meetings, and

work on assigned team tasks). Leadership

(e.g., managers and supervisors) can consider

specifying disaster planning responsibilities

in the job descriptions for team members and

taking into account those duties during each

employee’s annual review. 

Members of the disaster planning team 

can gain knowledge in all aspects of 

disaster planning and response through the 

Independent Study Program of the Emergency 

Management Institute (EMI), Federal 

Emergency Management Agency (FEMA). 

No-cost, online courses offered by EMI take 

approximately 3 hours to complete. They can 

be accessed at http://training.fema.gov/IS. 

Review Requirements for Disaster 

Planning 

The disaster planning team should review

pertinent accreditation, licensing, or

reimbursement requirements, as well as

any State and Federal regulations or laws

governing disaster planning. The team

should identify its program’s planning

requirements as dictated by its State, The

Joint Commission, CARF International, 

Medicaid, and any other bodies that govern

its operations. Team members also should

become familiar with Federal guidelines

regarding disaster planning. 
Disaster Planning Handbook for Behavioral Health Treatment Programs

Mandates may require the program to

conduct general disaster planning, as well as

specific planning for pandemic influenza (see

Chapter 6). Programs receiving State funding

may be required to have staff members (who

are credentialed and ready) participate in 

a behavioral health disaster response team. 

When a disaster occurs, such teams may be

mobilized by the State behavioral health

departments, or by specific lead organizations

serving localities, to provide affected members

of the public with psychological first aid,

crisis intervention, assessments and referrals 

to ongoing services, public information, and

other services as determined by the State

authority (Exhibit 2-2). Teams also may be

mobilized to support the behavioral health of

emergency responders (Exhibit 2-3). 

Exhibit 2-2. Mobilization of Behavioral Health Responders To Assist Hurricane Evacuees 

Colorado opened an empty dorm unit on the campus of the closed Lowry Air Force base for people 

who were relocated there after Hurricanes Katrina and Rita. In a gesture of welcome, a bar across the 

street from the dorm offered free drinks to the evacuees, with unintended consequences. The dorm 

took on the atmosphere of a Wild West town, with heavy drinking, clearly identified gang members, 

and prostitutes. Recovery advocates who visited the dorm identified and referred individuals in need of 

medication-assisted treatment, mutual-help group meetings, and, in some cases, medical detoxification. 

The presence of these recovery advocates helped many evacuees withstand the stress and temptations 

of the situation to preserve their recovery and obtain needed services. 

Source: Katie Wells, personal communication, May 11, 2010. 

Exhibit 2-3. Mobilization of Behavioral Health Responders To Assist 


Earthquake Emergency Responders
 

Steps taken in Haiti included psychological readiness preparation for responders before they were 

deployed and assistance with stress management, addiction risks, and other emotional and behavioral 

health concerns during deployment. Mental health professionals were embedded in National 

Disaster Medical System teams in Haiti and a mental health officer served on the Incident Response 

Coordination Team. In addition, responders received systematic post deployment education that 

included advice on expected responses and danger signs indicative of emotional and behavioral health 

problems and on how to access appropriate follow up resources should they be needed. Overall, this 

effort to include mental and behavioral health concerns in the response broke new ground and can 

serve as a model for the future. 

Excerpted from National Biodefense Science Board (2010, p. 15). 

Coordinate Planning With Others 

The program’s disaster plan should be

developed in coordination with the disaster 

planning of other behavioral health treatment 

programs, the State, the local jurisdiction,

neighboring businesses and voluntary

organizations, and Federal coordinating

agencies. Advance coordination can make the

program’s efforts in a disaster situation more

productive and the assistance it gives and

receives more effective. Treatment programs

are advised to participate in community

coordination of predisaster recovery planning

as outlined in the National Disaster Recovery 

Framework (U.S. Department of Homeland

Security [DHS], 2011a). 

Coordination with neighboring facilities and

organizations is especially important because

in any sizable disaster, the first assistance

is likely to come from or go to neighbors

(DHS, 2008). A behavioral health treatment

program is less likely to receive help in

community recovery efforts if neighbors do

not know that the program exists, or if they

do not understand that the program provides

essential services. The program is also less 

12 
13 

Chapter 2—Beginning the Disaster Planning Process

likely to be included in recovery efforts if

neighbors are unaware of the contributions

that the program and its staff can make in

responding to disaster. 

Furthermore, participating in the community’s

disaster planning can provide additional

opportunities to ensure the well-being of

the program’s clientele during a disaster.

For example, educating the community’s

disaster planning team on the importance of

appropriate reception into general population

shelters for individuals with behavioral health 

disorders (FEMA, 2010b) may help avoid

the types of discrimination seen in previous

disasters (Exhibits 2-4 and 2-5). 

Exhibit 2-4. Discriminatory Attitudes That Affected Care for People With Mental Disorders 

During Hurricanes Katrina and Rita, individuals with psychiatric conditions faced multiple forms of 

discrimination. Problems included denial of access to housing and other services and inappropriate and 

involuntary placement in jails, emergency rooms, nursing homes, and mental institutions. Group home 

residents were removed to new locations without prearrangement or tracking systems in place and 

could not be found by family members or their original providers. 

People with psychiatric disabilities “encountered enormous problems with general shelters” because 

such facilities were “crowded, noisy, chaotic, confusing, and sometimes violent, all inadequate 

circumstances for a person with psychosis, anxiety, or depression.” Some special needs shelters 

were available, but these were designed for people with medical and physical disabilities and so 

were inadequately prepared to support the needs of individuals with psychiatric disabilities. In some 

instances, the existence of a special needs shelter was used as an excuse to discriminate against 

individuals seeking access to the general shelters, with the result that some people with psychiatric 

disabilities were unable to obtain shelter altogether. 

Source: National Council on Disability (2006). 

Exhibit 2-5. Discriminatory Attitudes That Affected Care for People With Substance Use Disorders 

Interviews with employees of opioid treatment programs (OTPs) throughout the Gulf Coast region after 

Hurricanes Katrina and Rita suggest that discriminatory attitudes against people with substance use 

disorders—particularly those who were receiving dispensed methadone—complicated the ability of 

some individuals to receive needed services and compassionate care. 

In one community, evacuees who were being transported from a public shelter to an OTP for daily 

methadone dosing were required to have an armed police escort on the short bus ride. If officers were 

busy attending to other duties, the patients (as well as the staff members who would dose them) had to 

wait until an officer became available. In another community, a provider reported that police refused to 

allow patients access to the methadone clinic located past a floodlighted area, despite their having a 

physician letter stating that they were clinic patients. Networking with social service providers, educating 

them about substance abuse treatment, and establishing relationships with them before a disaster 

occurs may mitigate discrimination-related problems for clients during or after any such incident. 

Source: Podus, Maxwell, and Anglin (no date). 

Exhibits 2-6 and 2-7 provide examples in

which behavioral health treatment programs

networked with other community agencies

to improve their disaster preparedness.

The various groups with which a program’s

disaster planning team can coordinate are

described in the following sections and are

presented in a checklist in Worksheet B3 (in

Appendix B). 

State Disaster Behavioral Health 

Coordinator 

An important source for disaster planning

information, support, and coordination is the

State disaster behavioral health coordinator; 
Disaster Planning Handbook for Behavioral Health Treatment Programs

 

this official typically is located in the State

agency focused on behavioral health (e.g.,

Division of Behavioral Health Services, 

Department of Mental Health). Some States

have one person in this role, whereas others

have two disaster coordinators—one for 

mental health services and one for substance 

abuse treatment—sometimes operating out of

different agencies. For purposes of simplicity,

the following description is of the combined

position, the State disaster behavioral health

coordinator. This coordinator oversees the 

State’s behavioral health treatment response

plans and may work closely with programs

within the State to support coordination of

efforts in response to disaster. He or she

may also be in the position to offer disaster

training for programs. Serving as a liaison 

to other Federal, State, and local disaster 

responding agencies (e.g., the National

Guard), the coordinator can be a source of

information for the individual treatment 

program’s management and leaders of the

disaster planning team. 

Following a disaster that exceeds the local

response ability, the State disaster behavioral

health coordinator may become involved

in the application for, and distribution of,

disaster-related funds. These include any

available State and Federal funds (e.g., those

available through the Robert T. Stafford

Disaster Relief and Emergency Assistance

Act) and funds from two programs: (1) Crisis

Counseling Assistance and Training Program

(CCP) grants, which are funded by FEMA 

Exhibit 2-6. Networking To Improve Readiness for Disaster (Example 1) 

A behavioral health treatment program reported that it is among the first organizations in its community 

to get power back after outages because it is on the same priority electric grid as a nearby hospital. 

A drawback to this location is that during an emergency, authorities secure the area surrounding the 

hospital for emergency vehicles only. The OTP administrator worked with county government officials 

to have OTP staff members designated as emergency responders so that they could be provided 

with emergency responder IDs; these staff members now have ready access to the clinic when they 

encounter a roadblock. But challenges remain for patients trying to get to the program. After one 

hurricane, law enforcement officials set up a roadblock at a nearby intersection, where an officer 

demanded that patients show proof they were patients of the methadone program before permitting 

them inside the area. The administrator went to the roadblock with her patient list in hand and 

confirmed identities for police. “If I didn’t know the [patients] . . . if they were not a name on the list,” 

she reported, “they didn’t get in.” To avoid problems of this nature, programs are advised to ask law 

enforcement authorities about the circumstances under which access to their facility may be restricted 

and to negotiate in advance an access plan for staff and patients. 

Source: Podus et al. (no date). 

Exhibit 2-7. Networking To Improve Readiness for Disaster (Example 2) 

A behavioral health treatment program faced problems with the emergency evacuation traffic 

measures that were developed for its community. In an evacuation, the highway becomes a one-way 

thoroughfare heading out of town; once a vehicle enters the highway, it cannot exit to local streets. 

This presents the risk that clients and staff who are delayed at the clinic to complete dispensing of 

take-home medications when the emergency traffic pattern is implemented will be unable to return 

home to prepare for the community’s evacuation. To avoid problems of this nature, programs can ask 

local authorities for information about possible disaster traffic-control measures and road closures and 

ask community traffic planners for guidance on routes around potential roadblocks. However, program 

disaster planners should consider the possibility that, in an actual disaster, alternative routes may not be 

available and detours can greatly increase travel time, especially if power outages turn intersections with 

traffic lights into four-way stops. 

Source: Podus et al. (no date). 

14 
15 

Chapter 2—Beginning the Disaster Planning Process

and administered by the Substance Abuse

and Mental Health Services Administration 

(SAMHSA), and (2) SAMHSA Emergency

Response Grants (SERGs). 

CCP grants are made available after the

President authorizes an individual assistance 

disaster declaration, under which Federal 

aid can be directed to the provision of

professional counseling services, including 

financial assistance to State or local agencies or 

private mental health organizations to provide such 

services or training of disaster workers, to victims 

of major disaster in order to relieve mental health 

problems caused or aggravated by such major 

disaster or its aftermath (FEMA, 2007a, p. 47). 

CCP-funded projects include crisis counseling,

education, coping skills development,

assessments, referrals, and linkages to

services. The grants provide funds for either

60 days (Immediate Services Program grants)

or 9 months (Regular Service Program grants)

after the disaster declaration. 

SERG grants, which constitute “funding of

last resort” for behavioral health services, are 

disbursed when other State and local resources 

are unavailable; a Presidential declaration of 

disaster is not a requirement. SERG grants

are provided out of SAMHSA discretionary

funds dedicated to a variety of programs, which

means that SERG funding may not be available

when requested (Exhibit 2-8). For this reason,

programs should work with their State disaster

behavioral health coordinator in advance of any

disaster to identify multiple options for funding

after a disaster (Exhibit 2-9). 

Exhibit 2-8. Program Use of SERG Grants 

In 2005, shortly after Hurricane Katrina was declared a disaster by President Bush, the State of Texas 

applied for and received $150,000 in SERG funds to provide methadone to patients of OTPs who had 

evacuated into the State from Louisiana. These funds went to direct care and not to administrative support 

of providers. Three years later, Hurricane Ike hit Texas directly, damaging or destroying many substance 

abuse treatment facilities and forcing patients to relocate. Texas again applied for a SERG grant, but as 

it was so late in the fiscal year, no SERG funds were available. Some small providers were forced to close. 

Other providers worked with the State behavioral health authority to find other funding options. 

Source: Chance A. Freeman, personal communication, May 6, 2010. 

Exhibit 2-9. Distribution of Financial Aid in Louisiana After Hurricanes Katrina and Rita 

Following Hurricanes Katrina and Rita, the Robert Wood Johnson Foundation made funds available to 

help with replacement of equipment at substance abuse treatment facilities. These funds were available 

through a national nonprofit organization of treatment provider associations, the State Associations of 

Addiction Services (SAAS). At that time, Louisiana did not have its own State provider association, so 

SAAS passed funds to providers within the State via Louisiana’s Single State Agency (SSA) for substance 

abuse services. This coordination was critical to the restoration of treatment services in the State. 

Source: Michael Duffy, personal communication, April 21, 2010. 

SAMHSA’s Disaster Technical Assistance 

Center (DTAC) supports SAMHSA’s efforts to 

prepare States, territories, Tribes, and local 

groups to deliver effective behavioral health 

response during disasters. DTAC specialists 

can help a program link with the disaster 

behavioral health coordinator for its State, 

and they can answer questions and provide 

guidance on CCP grants and SERG funds. 

The DTAC Web site links to a resources listing 

of more than 1,500 materials. It is located at 

http://www.samhsa.gov/dtac. For technical 

assistance, contact DTAC at 1-800-308-3515, 

or at DTAC@samhsa.hhs.gov. 
Disaster Planning Handbook for Behavioral Health Treatment Programs

 

 

 

State disaster behavioral health coordinators 

can serve as liaisons with external emergency

response teams from the U.S. Public

Health Service Commissioned Corps or

teams coordinated by National Voluntary

Organizations Active in Disaster (see

Voluntary Organizations, below). These teams,

which can include behavioral health specialists,

are sent into communities to respond to public

health crises and national emergencies. In

addition, some State disaster behavioral 

health coordinators are directly responsible

for assembling behavioral health disaster

response teams comprising staff members from

programs operating in the State. 

Finally, the State disaster behavioral health

coordinator may help programs affected by

disaster obtain precredentialed volunteer

assistance through the Emergency System for

the Advance Registration of Volunteer Health

Professionals. This State-based registration

system for volunteer professionals includes

licensed behavioral health treatment 

counselors and other clinicians (U.S.

Department of Health and Human Services

[HHS], 2008). 

Part 1 of Worksheet B4 (in Appendix

B) contains a checklist of topics that

representatives of the disaster planning

team can address with their State disaster 

behavioral health coordinator. 

Behavioral Health Treatment Programs 

As an initial collaborative step, the disaster

planning team is advised to reach out to

representatives from other behavioral health

treatment programs located in the community 

and region. Programs need to collaborate so

that they are prepared to assist each other’s

displaced populations in situations where

one of them is unable to provide essential

services or has clients who must relocate. 

Such programs can share information and

resources on disaster planning and coordinate 

participation in the broader community’s

local emergency planning. The State disaster

behavioral health coordinator can facilitate 

these connections. 

Public Health Department 

Public health departments are first

responders to incidents that can affect

public health. Responsibilities of the public

health department vary by jurisdiction, but

may include: coordination of the healthcare

system throughout the jurisdiction to ensure

continuity of essential functions and to avoid

interruption of patient and client care; setup

and operation of alternate medical care

facilities or shelters for people who need

medical care; support to healthcare partners

in resource management and coordination;

distribution of medications from the Strategic

National Stockpile; mass vaccination;

coordination of disaster advance training for

healthcare personnel; and other duties. 

National standards oblige public health

departments to coordinate disaster

planning with the community’s behavioral

health treatment systems (HHS, 2011b).

For example, the Capability Standard for

Community Preparedness notes that (HHS,

2011b, p. 10): 

By engaging and coordinating with emergency 

management, healthcare organizations (private 

and community-based), mental/behavioral health 

providers, community and faith-based partners, 

state, local, and territorial, public health’s role in 

community preparedness is to do the following: 

• Support the development of public health, 

medical, and mental/behavioral health 

systems that support recovery. 

• Participate in awareness training with 

community and faith-based partners on how 

to prevent, respond to, and recover from 

public health incidents. 

• Promote awareness of and access to 

medical and mental/behavioral health 

resources that help protect the community’s 

health and address the functional needs 

(i.e., communication, medical care, 

independence, supervision, transportation) of 

at-risk individuals. 

16 
17 

Chapter 2—Beginning the Disaster Planning Process

 

 

 

• Engage public and private organizations 

in preparedness activities that represent 

the functional needs of at-risk individuals 

as well as the cultural and socio-economic, 

demographic components of the community. 

• Identify those populations that may be at 

higher risk for adverse health outcomes. 

• Receive and/or integrate the health needs of 

populations who have been displaced due to 

incidents that have occurred in their own or 

distant communities (e.g., improvised nuclear 

device or hurricane). 

Standards in other capability areas (such

as Community Recovery and Mass Care)

also require coordination with providers of

behavioral health treatment services. 

The health department represents

Emergency Support Function (ESF) #8

(Health and Medical) services at the Local

Emergency Planning Committee, which

exists in every jurisdiction to pursue federally

directed objectives for emergency planning.

The health department also may represent

behavioral health and medical functions at 

the Emergency Operations Center that the

community would establish during a disaster.

Another role potentially played by the health

department would be to relay requests for

community assistance from behavioral health

programs, as needed in a disaster situation.

The public health departments coordinate 

their efforts with the requirements set forth

by the State departments of health. 

The public health department’s emergency

manager can provide planners from behavioral

health programs with targeted planning

assistance and can serve as a link between the 

programs and broader disaster planning and

incident response efforts. Ideally, behavioral

health treatment programs in a community

collaborate on initial planning and then

collectively approach the health department’s

emergency manager for integration into

the community’s planning activities. Some

States organize public health departments by

county, in which case the ideal is a countywide

collaboration by programs, for purposes of

working with their health department. 

Exhibit 2-10 describes how a regional

network of healthcare organizations

collaborates extensively for disaster planning.

Part 2 of Worksheet B4 (in Appendix B)

contains a checklist of topics that the team’s

representative can address with the public

health department. 

Exhibit 2-10. Collaborative Planning by Healthcare Organizations 

The King County Healthcare Coalition in the State of Washington is a network of healthcare organizations 

(i.e., behavioral health treatment programs, hospitals, nursing homes, adult family homes, surgical centers, 

dialysis providers, blood centers, and government agencies involved in public health). The coalition develops 

and maintains a comprehensive system that helps ensure coordination, effective communications, and 

optimal use of available health resources in response to emergencies and disasters for all hazards. 

Since 2005, the coalition has focused on three major initiatives: building infrastructure to support a 

coordinated, regional emergency response across the healthcare system; strengthening each healthcare 

organization’s continuity plan and emergency preparedness; and developing surge capacity and 

capability strategies that address public health service needs during disaster. 

The coalition is making plans for alternate care facilities, a regional call center to manage demand for 

disaster-related health and medical information, and a health and medical volunteer management 

system to provide the staffing required supporting that demand. 

Source: Michael Duffy, personal communication, April 21, 2010. 

Strengthening Emergency Response Through 

a Healthcare Coalition: A Toolkit for Local 

Health Departments is a toolkit to support 

development of healthcare coalitions. 

Developed by the King County Healthcare 

Coalition, the toolkit can be accessed at 

http://www.apctoolkits.com/kingcountyhc. 
Disaster Planning Handbook for Behavioral Health Treatment Programs

Emergency Response Organizations 

A good practice is to provide a copy of

the program’s facility floor plan to local

emergency responders (e.g., police and

fire departments). The floor plan should

indicate the locations of personnel who

typically occupy the premises. Local

emergency responders should be informed

of whether controlled substances (e.g.,

barbiturates, methadone) that may require

special protection during emergencies are

stored onsite. If so, the responders should

be informed where on the premises such

substances are located. Additionally, local

emergency responders should be notified

as to whether people onsite need special

assistance in exiting the facility. To find the

right department for filing a floor plan, call

the nonemergency phone number of the police

or fire department. 

In some evacuations, the choice of where to 

take people is made on an ad hoc basis by

emergency responders (National Council on

Disability, 2006). A representative of the

disaster planning team can educate local

emergency response organizations about: 

•	 The characteristics of the program’s

residential patients (especially residents

of group homes or other 24/7 residential

treatment programs). 

• The needs of these individuals during and

after transport. 

• The types of settings that would be most

appropriate for them to be taken to when

they are being relocated. 

•	 The specific locations (such as another

residential treatment program) that have

been pre-arranged to accept patients in an

evacuation, if such pre-arrangements have

been made (see Negotiate Memoranda of

Agreement, in Chapter 3). 

The treatment program can work with

emergency responders to ensure that in an

evacuation its patients are not automatically

routed to special needs shelters, institutions,

nursing homes, or hotels rather than to a 

general population emergency shelter that is

more likely to offer a fuller range of support

services (e.g., assistance in transitioning

back to permanent housing). Patients have

a right to expect from general population

emergency shelters support services that

enable them to maintain their independence

in that shelter (FEMA, 2010b). This includes,

among other things, access to medications to

maintain health, mental health, and function; 

refrigeration for medications; and assistance

that may be required due to cognitive and

intellectual disabilities. 

Local Office of the Drug Enforcement 

Administration 

The local Drug Enforcement Administration

(DEA) agent monitors and reviews actions

the program takes in a disaster regarding

controlled substances (e.g., relocating a

methadone supply to an alternate facility)

(see Chapter 5). The treatment program’s

disaster planning team can inform the

local DEA agent about the use of controlled

substances that are prescribed or dispensed

to patients and stored at the facility

(e.g., anti-anxiety medications such as

benzodiazepines, central nervous system

stimulants such as methylphenidate

[Ritalin] for treatment of attention deficit/

hyperactivity disorder, methadone for opioid

dependence). The team also can invite the

DEA agent to participate in its disaster

planning. These actions may expedite

DEA decisions affecting the facility during

a disaster. The State Opioid Treatment

Authority can assist in making contact with

the local DEA official. 

Organizations of Pre-Credentialed 

Volunteers 

The Emergency System for Advance

Registration of Volunteer Health

Professionals (ESAR-VHP) is a Federal

program through which States and territories

register health professionals who can

provide volunteer service in disasters and

public health and medical emergencies.

The program verifies the identification and 

18 
Chapter 2—Beginning the Disaster Planning Process

licenses, credentials, accreditations, and 

hospital privileges of each health professional

volunteer so that in a disaster incident the 

volunteers can be quickly deployed, across

State lines if needed. 

The Citizen Corps is a national service

program that mobilizes volunteers for

emergency preparedness and assistance

in recovery after a disaster or terrorist

attack. The program supports personal

preparedness planning, provides training,

and coordinates volunteer services. Each 

community has a Citizen Corps Council

(CCC) to carry out the national program’s

objectives locally. Sponsored by the Office of

the Surgeon General and a component of the

Citizen Corps, the Medical Reserve Corps

(MRC) is a grassroots, nationwide network

of volunteer medical and public health

professionals who contribute their skills and

expertise throughout the year and in times of

community need. 

In a disaster, assistance from either the 

ESAR-VHP or a CCC to the behavioral health 

treatment program would be provided through

the community’s Emergency Operations

Center or through a State coordinator. The

behavioral health program’s disaster planning

team may choose to make proactive contact

with these organizations to register its own

staff. If no local MRC unit exists, the disaster 

planning team may want to work with

community leaders to establish one. 

Appendix D, Disaster Planning Web 

Resources, provides links to organizations of 

pre-credentialed volunteers. 

Voluntary Organizations 

Local nonprofit or nongovernmental groups,

especially those affiliated with the coalition

National Voluntary Organizations Active

in Disaster, can serve as facilitators and 

gatekeepers for emergency services. These

groups include: 

• The American Red Cross—A prominent

provider of disaster shelter, supplies, and

services, including tools for communicating

with volunteers and partners in disaster

conditions. The organization also provides

disaster services training through

certification courses (held online and at

local chapters) for potential volunteers,

including medical professionals who may

be called upon to assist in Red Cross

shelters. 

• Faith-based organizations, service

fraternities, sororities, and clubs—These 

often have resources, trained volunteers, 

and facilities to support the response

efforts of disaster teams. 

• Mutual-help and recovery groups or

advocates (e.g., self-help groups for

recovery from mental or substance use

disorders, individuals credentialed by

the National Alliance for Medication 

Assisted Recovery)—These programs and

people can provide psychological support

to individuals in recovery and affected by

disaster. 

• Consumer advocacy groups—These can be

helpful in coordinating disaster support

for particular client populations, such

as people with cognitive or intellectual

disabilities (see Prepare Clients for a

Disaster, in Chapter 3). 

Depending on the type of organization and

the circumstances, a wide variety of help

may be available to those affected by the

disaster (e.g., meals; water; housing; clothing;

toiletries; grant-writing help; replacement

furniture and equipment; cleanup and

reconstruction supplies, tools, and labor).

Voluntary organizations may also be able to

provide assistance with medication pickups,

transportation to appointments, contacting

family members, and other specific tasks.

Some volunteer groups provide disaster

case management services, which can be

especially helpful for clients with disabilities

including behavioral health disorders

(Stough, Sharp, Decker, & Wilker, 2010). In a

disaster situation, assistance from volunteer 

organizations would be requested through the 

19 
Disaster Planning Handbook for Behavioral Health Treatment Programs

ESF #8 lead at the Emergency Operations

Center; this is most likely the emergency

manager at the local health department (see

Public Health Department, above). 

Federal guidelines for emergency shelters

call for the inclusion in planning of people

with mental health expertise as well as input

from people with disabilities, access issues,

or other functional needs (FEMA, 2010b).

The guidelines also recommend that one or

more licensed mental health professionals be

present in a general population shelter or on

call at all times. 

The disaster planning team can meet

with representatives from the voluntary

organizations that operate shelters (and the

mutual-aid groups that work in them) so

that staff and clients of the behavioral health 

treatment program can learn how to access

these shelters under disaster circumstances. 

In addition, such meetings present an

opportunity to advocate for client needs and

rights in a shelter setting. Issues that can be

addressed include: 

• Procedures for certifying and credentialing

medical professionals and volunteers for

access to, and providing services in, that

organization’s shelters. (Access to some

shelters may be blocked by security or law

enforcement personnel for anyone without

such credentials.) 

• Procedures to assist individuals in 

obtaining medications prescribed to them. 

• Procedures for enabling clients in

emergency shelters to meet with treatment

counselors, recovery advocates, or mutualhelp groups. 

• Admitting procedures at shelters for

people who have psychiatric medications

or methadone take-home doses in their 

possession. 

• Procedures for handling medications (e.g.,

documenting in writing any medications

brought into the shelter that remain

in the possession of the individual, are 

turned over to staff for dispensing, or are

confiscated). 

• First aid principles for identifying and

assisting shelter residents who have

psychotic symptoms, are in withdrawal, or

have other symptoms of behavioral health

disorders. 

Vendors and Other Nearby Businesses 

The disaster planning team can ensure that

contingency plans are in place with suppliers

of the goods and services that will be needed

to respond to disaster (e.g., companies that

provide fuel, water, medications, building

supplies, dry ice for refrigeration in case of

power outage, vans or buses for evacuation,

snowplowing service, food services for

residential programs, water damage repair). 

Evacuation, sheltering-in-place, and

mitigation are disaster-related activities that

are best accomplished in coordination with

neighboring organizations. Representatives

of the disaster planning team can meet

with nearby businesses to share contact

information, identify resources in the

neighborhood, and develop relationships for

working together in a disaster. It is especially

important to coordinate with any businesses

located in the same building to facilitate the

sharing of resources when sheltering-in-place. 

Media 

Local radio stations, which can be listened 

to even when local electrical power is

disrupted (e.g., via car or solar radios), can

be a powerful resource for coordination.

The disaster planning team can request the

program’s inclusion in local radio and TV

emergency listings. For example, local media

can inform the public of the operating status

of the program (e.g., open, closed, delayed

opening, operating in an alternate location).

In a disaster situation that affects more 

than the program alone, messages to the

general public should be coordinated with

the community via the Public Information

Officer of the community’s Incident Command 

System (see Chapter 3). 

20 
21 

Chapter 2—Beginning the Disaster Planning Process

Educate the Community About 

Behavioral Health Services 

An important objective that programs can

accomplish in making the linkages described

above is educating the community about

the special importance of behavioral health

services in disaster situations. Ideally in

coordination with other local behavioral 

health programs, the disaster planning team 

can identify and arrange for opportunities

to teach others (e.g., community leaders,

private and public partner organizations,

volunteer agencies, representatives from the

faith-based community) about the program’s

mission, the treatment and recovery services

the program provides, and the contributions

the program can make to the community’s

behavioral health disaster preparedness.

Exhibit 2-11 provides an example of mental 

Exhibit 2-11. Sample of a Disaster-Specific Prevention Message
 

Coping With the Gulf Oil Spill—Mental Health Information
 

Practical advice on how to deal with the effects
 

the Gulf oil spill can have on your mental health
 

Intense Feelings Are Expected 

Over the years the residents of the Gulf coast have demonstrated remarkable resilience. Individuals, 

families, and communities impacted by the oil spill are taking steps to adjust and adapt to the situation. 

The reaction to financial and personal stress created by the spill is different for each person. Most may 

not need any help, or they may need only a little extra support to help them cope with the change in 

livelihood. 

Talk About Feelings With Friends and Family 

Talking about the way you feel and taking care of yourself by eating right, getting enough sleep, 

avoiding alcohol, and getting some exercise can help to manage and alleviate stress. 

Take Care of Each Other 

Check in with your friends and family members to find out how they feel. Feeling stressed, sad, or upset 

is a common reaction to life-changing events. Learn to recognize and pay attention to early warning 

signs of serious problems. 

Know When To Seek Help 

Depending on their situation, some people may develop depression, experience grief and anger, turn 

to drugs and alcohol, and even contemplate suicide. The signs of serious problems include: 

• Excessive worry. 

• Frequent crying. 

• An increase in irritability, anger, and frequent arguing. 

• Wanting to be alone most of the time. 

• Feeling anxious or fearful, overwhelmed by sadness, confused. 

• Having trouble thinking clearly and concentrating and difficulty making decisions. 

• Increased alcohol and/or substance use. 

• Physical aches, pains, complaints. 

If these signs and symptoms persist and interfere with daily functioning, it is important to seek help for 

yourself or a loved one. 

Excerpted from HHS (2010). 
Disaster Planning Handbook for Behavioral Health Treatment Programs

health information that a behavioral 

health treatment program can share with a

community that is recovering from a disaster.

(When called on, the program should make

a good-faith effort to fulfill whatever it

has promised to contribute; otherwise, the

program may be less welcome in future

collaborative planning.) 

One way of educating the community about

behavioral health services is to invite other 

community partners to disaster trainings for

staff and provide the materials, free of cost.

This would provide an opportunity to discuss

the role, mission, and scope of services offered

by the behavioral health treatment program,

both in a disaster and in general. A secondary

goal would be to increase the awareness of

individual and community preparation. 

The program can share general information

concerning populations with which it has

expertise (e.g., adolescents, older people,

pregnant and postpartum women) and

advocate for consideration of their special

needs in disaster planning. The program

also can emphasize to local leaders that,

during a disaster, individuals needing

behavioral health treatment (e.g., support

and medication for mental or substance use 

disorders) should have the same priority 

as individuals needing care for other

conditions (e.g., support and medication

for epilepsy, diabetes, heart ailments,

asthma). Information about the program’s

specific vulnerabilities should be conveyed

to community leaders so that, in a time of

disaster, its urgent needs are taken into

consideration as community response efforts

and resources are allocated. 

A valuable contribution that a behavioral 

health treatment program can make to 

community disaster planning is to introduce 

planning partners to the NIDAMED Resources 

for Medical and Health Professionals. This 

initiative provides resources and information 

about how providers in primary care settings 

can provide: alcohol, tobacco, and drug 

screening (including an online interactive 

drug use screening tool); brief interventions; 

and treatment. It is located at http://www. 

drugabuse.gov/nidamed-medical-healthprofessionals. 

Exhibit 2-12 describes the problems that

occurred because, in advance of Hurricane 

Katrina, behavioral health treatment 

programs had not established clear

procedures with the voluntary organizations

that operated local emergency shelters. 

Exhibit 2-12. Example of Need To Coordinate With Voluntary Organizations 

Immediately following Hurricane Katrina, the American Red Cross established a shelter in Baton Rouge, 

LA, which housed more than 1,200 people. Officials from Louisiana’s SSA for substance abuse services 

met with shelter staff to arrange an opportunity for individuals in the shelter to meet with substance 

abuse treatment counselors. SSA obtained permission to set up a booth inside the shelter and planned 

to use impaired eye goggles (simulating the effects of substance use) as a novelty item to attract people 

to the booth. The staff would conduct screening, brief intervention, and referral to treatment (SBIRT) 

as indicated. At 6 a.m.—before counselors arrived at the booth—SSA was contacted by officials from 

the Governor’s Office and the State and local police. The officials said that they understood the SSA 

planned to conduct urine drug testing on all individuals being housed at the shelter and ordered them 

not to do so. This miscommunication occurred because information about the purpose of the booth 

was passed along informally among shifts and distorted into a false rumor. The misinformation was 

corrected, and staff members were deployed to the shelter. This incident demonstrates that advance 

coordination may help avert the miscommunications that can occur when attempting to coordinate 

activities in the midst of a disaster. 

Source: Michael Duffy, personal communication, April 21, 2010. 

22 
23 

Chapter 2—Beginning the Disaster Planning Process

Strong relationships with others in the

community also can lay the groundwork for

the sustained support that may be needed—

over weeks, months, or even years—to help

the program and its clients recover from a

disaster’s effects. 

Prepare a Hazard Identification 

and Risk Assessment 

Once the disaster planning team is formed

and educated regarding its mission and

scope and has identified the planning

partners in the community, its first priority

is to obtain and review an assessment of 

its community’s particular vulnerabilities.

Typically, a community already has

prepared such a document, called the hazard 

identification and risk assessment (HIRA)

or the threat and hazard identification and 

risk assessment (THIRA). A copy can be

requested from the planning team’s contact

at the public health department or from

the community’s emergency manager, if

different. The HIRA identifies the types and

scopes of hazards most likely to occur in the

jurisdiction. 

By using the community’s preexisting

assessment as a foundation, the disaster 

planning team can make informed decisions

about its own priorities for disaster planning,

assess the capacity of the organization

to respond to such hazards, and plan to

meet any gaps in the ability to respond.

Furthermore, it can plan disaster response

measures that align with other local

response plans. The HIRA serves as the

basis of planning disaster responses that

are particular to the region that a program

serves. It can be included in the planning

assumptions section of the basic plan and

should be used to determine which hazardspecific appendices are prepared and

documented in the plan. 

Hazard risks differ depending on their type

and scope. Types of hazards include natural 

(events related to weather, geography, or

pandemic infectious disease), technological 

(potential disasters involving human-made

materials and stemming from technological

or industrial accidents or negligence), and 

human caused (potential disasters caused by

human accident, civil unrest, or deliberate 

action). The scope of a hazard can be 

internal (only one location of the program is

affected), local (the program in one locality,

its community, and the local infrastructure

are affected, including nearby hospitals,

businesses, and schools), or regional 

or national (the hazard affects a broad

geographical area). 

All hazards present risks of injury,

psychological trauma (including panic), or

death for clients and staff members, as well 

as health risks to clients who experience

sudden interruptions in care and potential

public safety issues if individuals with

addiction resort to illegal acts to procure

drugs. Examples of other hazard-posed risks

to behavioral health treatment programs

include the following: 

• Destruction of property, medications, and

clients’ treatment and billing records 

• Damage to facilities or properties that

make access difficult or unsafe 

• Damage to community infrastructure

including landline telephone service,

utilities (e.g., water, sewage, electricity),

and transportation facilities 

• Disruption in the delivery of supplies (e.g.,

medications, linens, food) 

• Clients unable or reluctant to travel to the 

facility for services 

• Staff shortages 

Program-specific factors can affect the

program’s vulnerability to hazards, as

well as its strengths in responding to a

disaster (Exhibit 2-13). Depending on the

characteristics of the disaster, a program may

be able to continue operations by relying on

its resources, or it may need assistance from

the community or local, State, and Federal 

governments. 
Disaster Planning Handbook for Behavioral Health Treatment Programs

Exhibit 2-13. Examples of Program Vulnerabilities and Strengths in a Disaster 

Factor Potential Vulnerabilities Potential Strengths 

General 

Location 

The program is situated, for example, in a flood 

plain or in a building that does not meet safety 

codes. 

The program is situated, for example, on 

high ground above floodwaters or in an 

earthquake-proof building. 

Rural 

Location 

The program is far from emergency rescue 

stations, hospitals, and other resources that will 

be helpful in a disaster. 

The program is more prepared for selfreliance because of its relative isolation in 

normal times. 

Urban 

Location 

The program faces an overwhelming demand for 

services from its populous community. 

The program can refer its overflow to 

nearby programs. 

Community 

The program is isolated from or misunderstood 

by its community. Cultural barriers separate the 

community from the program. The community 

does not know what the program would need or 

can offer in a disaster. 

The program is well integrated into the 

community and is connected by cultural 

ties. The community is aware of what 

the program will need and can offer in a 

disaster. 

Recovery 

Support 

The program is not networked into the local 

recovery communities. Recovery advocates are 

not prepared to respond to the needs of the 

program and its clients after a disaster. 

The program has close ties to the 

recovery community. Recovery advocates 

have been prepared and pre-credentialed 

to offer practical assistance to the 

program and its clients in a disaster. 

Capacity 

The program is small in terms of staff and 

resources, which puts it at risk of being 

overwhelmed by a disaster and increasing the 

chance that it will have to close. The program 

does not have the resources (e.g., reserve fund, 

inventory, insurance, budgeted line items for 

disaster response) to endure the disaster period, 

absorb losses, and avert closure. 

The program has sufficient staff and 

resources so that in a disaster it can scale 

down yet still provide essential services 

to clients. The program has enough 

resources to survive the disaster and its 

aftermath. 

Specify Planning Objectives 

and Assumptions 

The disaster planning team can best focus its

efforts and avoid working at cross-purposes

if it establishes planning objectives and if

it bases planning on accurate assumptions.

Objectives and assumptions are documented

in the basic plan. 

Planning objectives are the outcomes that the 

team seeks to attain by developing a disaster

plan, such as the following: 

• Minimize hazards and risk of disaster. 

• Ensure the safety of all employees, clients,

and visitors. 

• Promote personal and family disaster

planning by staff members. 

• Prepare the organization for continuous

provision of essential services to clients

and staff (and affected family members,

whenever possible) during and after a

disaster. 

• Plan reengagement strategies, to be

initiated after a disaster is over, for clients 

who have not finished treatment or who 

were involved in nonessential services. 

Each annex to the plan also may include

additional objectives. For example, the annex

that includes the continuity plan can include

objectives, such as the following (FEMA,

2004): 

• Identify essential operation functions, staff

positions responsible for maintaining those

functions, and position descriptions. 

24 
25 

Chapter 2—Beginning the Disaster Planning Process

• Put in place succession planning to

maintain operations if primary positions

become vacant. 

• Ensure that operations related to the

continuity of the business are sustainable

for a given number of days. 

• Ensure that operations that have been

shut down because of the disaster can 

resume within a given time period. 

Planning assumptions are best guesses about

the physical and operating environments that

will be in place at the time a disaster occurs.

Examples include: 

• The amount of time it takes emergency

responders (e.g., police, firefighters,

emergency medical technicians) to reach

the facility under normal conditions. 

• A typical number of staff, clients, family

members, and visitors on the premises or

in residence at any one time. 

• The times of day when staff and clients are

on the premises and services are provided. 

• The quantity and types of medications

stored at the facility, especially controlled

substances (e.g., benzodiazepines,

methadone) (see Chapter 5). 

• The frequency with which client records

are updated and either printed for a paper

filing system or migrated electronically to 

a remote computer server. 

• Recognition that a disaster can occur at

any time and during any shift and can

reduce the size of the workforce available 

to perform essential functions. 

• Recognition that disaster response

relies primarily on the staff preparation,

equipment, and Memoranda of Agreement

that the program has in place before the

disaster occurs. 

Chapter 3—Preparing for Disaster
 

In This Chapter 

•	 Mitigate Risk 

•	 Negotiate Memoranda of

Agreement 

•	 Designate Personnel To

Assume Command for 

Incident Response 

•	 Prepare Clients for a Disaster 

•	 Obtain Client Locator 

Information 

•	 Encourage Staff To

Make Plans for Personal 

Preparedness 

•	 Prepare Staff for Supporting

Clients in Disaster 

•	 Prepare To Connect

Clients to Disaster Case 

Management 

•	 Ensure Counselor Access to 

Shelters 

•	 Prepare for Financial

Resiliency 

Worksheets (see Appendix B) 

•	 B5 Sheltering-in-Place

Checklist 

•	 B6 Record of Memoranda 

of Agreement and Qualified

Service Organization

Agreements 

•	 B7 Incident Command 

System Positions 

Once the behavioral health treatment program’s

disaster planning team has been organized, oriented

itself to its tasks, forged connections with community

planning partners, and reviewed risk assessments

(Chapter 2), it can progress to the next important

preparedness activities. This chapter provides

guidance on risk mitigation, readiness support to

clients and staff, and other advance planning issues. 

Mitigate Risk 

The disaster planning team can help its program avoid

discontinuation of essential services by working with

management to prepare the program and its facilities

in ways that will lessen the impact of a disaster

when it does occur. Such actions are referred to as 

mitigation. These actions are guided by the program’s

hazard identification and risk assessment (see Chapter 

2). Mitigation examples include the following: 

• Making changes to the building and grounds to

improve the facility’s capacity to withstand a

disaster. Examples: Secure shelves and appliances

to wall studs to prevent them from falling if

earthquake is a likely hazard. Clear the facility’s

outdoor property of flammable material and debris

if wildfire is a risk. 

• Preparing to shelter-in-place for disasters in which

it would be either impossible or unsafe for staff and

clients to evacuate. Examples: Identify and prepare

a safe room in the basement or interior of the 

building for sheltering from tornado. Ensure that

the space is sufficient to house the average number

of people (clients, staff members, and visitors) on

the premises at any one time. (See Worksheet B5 

in Appendix B.) 

• Planning for building evacuation. Examples: Stock

evacuation chairs or slings and other equipment to

enable swift removal of people who need assistance.

Train staff in the use of this equipment. 

• Stocking supplies. Example: Store cots, linens, and

nonperishable food items for emergencies during

which staff members must stay overnight. 

27 
Disaster Planning Handbook for Behavioral Health Treatment Programs

• Preparing staff and clients onsite for personal

disaster response. Example: Stock portable

bags (personal go kits), one per person at the

facility, that include emergency evacuation

supplies (e.g., water bottle, flashlight with

batteries) (Exhibit 3-1). 

To limit as much as possible the extent to

which staff members are affected by any

disaster that occurs, the treatment program’s

disaster planning team can identify ways to

support staff in home disaster planning. Staff

can be directed to Federal guidance for the

disaster readiness of individuals and families 

(e.g., preparing a family emergency supply

kit, developing a family emergency plan for

evacuation and for staying in contact, and

becoming familiar with appropriate actions to

take during an emergency). 

Exhibit 3-2 demonstrates the importance of

preventive action to lessen the impact of a

disaster, and Exhibit 3-3 contains examples

of mitigation specific to behavioral health 

treatment programs. 

Negotiate Memoranda of 

Agreement 

In the context of disaster preparedness, a 

Memorandum of Agreement (MOA; also called 

a Memorandum of Understanding, or MOU),

is a document that defines how one party will

assist another on request. When the agreement

is bilateral or multilateral, the document may

be referred to as a mutual aid agreement. MOA 

can be arranged among all programs within

a county or State, and they can be arranged

State-to-State, to plan for disasters with wide

geographic impact. The optimal situation is to

have written agreements prepared in advance

and reviewed by all parties, either annually or

when relevant circumstances change (Exhibit

3-4). If needed, they can be arranged after the

fact (Exhibit 3-5). 

Examples of issues that might be covered in

an MOA include the following: 

• Arrangements for use of alternate facilities 

Exhibit 3-1. Welcome Bags and Personal Go Kits 

Our team has created welcome bags for our residential intake clientele that contain toiletries as well as 

comfort items such as a blanket, a journal, a deck of cards, a novel or book of meditation, a portable 

media player, scented candles, and so forth. We also put clothing (sweat suits and t-shirts—sized at 

admission) into the welcome bags of patients who are emergency intakes and have not had time to 

prepare for admission. We prepare 20–30 welcome bags at a time so that we always have an adequate 

inventory and try to have 10 for each gender on hand at all times. The welcome bags are backpacks 

with designated ID tags and space for storage of medication should the need arise for evacuation. We 

also store about 40 smaller emergency go kits in the same location. These contain potable water, highenergy food bars, and other foods with long shelf life, such as dehydrated fruits. The go kits are stored 

near the welcome bags to be placed in the backpacks or provided to staff as needed. 

Source: Michael Lynde, personal communication, April 26, 2010. 

Exhibit 3-2. Preparing for Power Failure 

An inpatient behavioral health treatment program in the State of Washington had court-ordered individuals 

among its patients. To allow someone to exit through the facility’s doors, a code had to be entered into 

an electronic keypad. When the power failed, the doors automatically unlocked—to the surprise of the 

program’s administrators—and some of the court-ordered patients nearly escaped. Although the facility had 

a generator, the electronic keypads were not connected to it. After this incident, the facility’s staff connected 

the electronic door system to the generator and instituted a policy of regular testing. 

Source: Michelle McDaniel, personal communication, August 14, 2009. 

28 
29 

Chapter 3―Preparing for Disaster

• Agreements to provide essential services 

on a temporary basis to another program’s 

clients when needed 

• Agreements to support computer system 

needs in a move to an alternate location 

Exhibit 3-3. Examples of Disaster Mitigation Specific to a Behavioral Health Treatment Program 

• Store medications in a safe, locked area that can be protected from the most probable hazards. For 

example, programs in flood-prone areas can store medications above ground level, whereas programs 

that are in earthquake-prone areas can store medications in cabinets that are secured to an interior wall. 

• Maintain a 3-day supply of water, food, linens, garbage bags, sanitation products, and other provisions to 

sustain the maximum number of people who may be on the premises at any one time. This includes clients, 

staff members, volunteers, and visitors. The supply should include provisions particular to people who may be 

on the premises and who are defined as at-risk (U.S. Department of Health and Human Services, 2012) (e.g., 

children, senior citizens, pregnant women, those with chronic medical disorders, those with pharmacological 

dependency) as well as provisions for any pets or service animals on the premises. Keep an inventory of these 

supplies, and check the expiration dates as necessary to ensure their safety and effectiveness. 

• Keep coolers onsite for use when transferring refrigerated medications in an evacuation. 

• Ensure that electricity-dependent systems, such as security alarms or water pumps, have battery 

backups or are connected to generators that automatically launch if power is lost. 

• Ensure and test all means of exit from buildings, such as elevators and stairwells, that may be affected 

by power outages. 

Exhibit 3-4. Negotiation for Assistance in Hurricane Season 

During hurricane season in South Florida, small behavioral health treatment programs in vulnerable 

areas, such as the Keys, have evacuation and transfer agreements with larger programs located in 

metropolitan areas. Programs evaluate the necessity of evacuating and transferring clients based 

on advisory information from local and State officials and from the National Hurricane Center, which 

provides information on a continuous basis about the patterns and severity of an approaching hurricane. 

Evacuation and transfer agreements are ongoing and include plans for client continuity of care. Most of 

the programs’ agreements also include plans for the relocation and transfer of the staff members who 

will provide needed services to clients. The objective is to conduct evacuation and transfer at least 24 

hours before the predicted landfall of an approaching hurricane. 

Source: John Lowe, personal communication, January 8, 2009. 

Exhibit 3-5. Negotiation for Mutual Aid Following a Major Snowfall 

In winter 2009, the State of Washington experienced an unexpected heavy snowfall—more than 5 feet 

of snow fell within a month in some areas. As temperatures rose and snow melted, flood risk increased. 

An opioid treatment program (OTP) administrator became concerned that her facility might have to 

close temporarily. She contacted an OTP in neighboring King County to arrange for guest dosing of her 

program’s methadone patients. This neighboring OTP was a party to a mutual aid agreement (arranged 

under the auspices of the King County Healthcare Coalition) that described the terms under which King 

County OTPs would provide guest dosing services to one another. The King County OTP used this 

mutual aid agreement as a template for a new agreement between itself and the OTP located outside 

King County that was at risk of flooding. Fortunately, the patient transfer was not needed, and the two 

OTPs now have an agreement in place for future use. 

Source: Michelle McDaniel, personal communication, August 5, 2009. 
Disaster Planning Handbook for Behavioral Health Treatment Programs

 

• Provision of evacuation transportation

assistance 

• Lending or borrowing personnel to

temporarily fill key staffing gaps (Exhibit

3-6) 

• Payment arrangements for any of the

above 

Other details that typically are covered in a

mutual aid agreement include the roles and

the scope of responsibilities of each party;

procedures for requesting, providing, and

ending aid; procedures for reimbursement

and allocating costs between the parties

to the agreement; and communications

compatibility issues (e.g., for running client

record software on another program’s

hardware systems; see Ensure Interoperable

Communications, in Chapter 4). Other topics

a mutual aid agreement might cover include

mechanisms for invoking and revoking the

agreement and liability and immunity issues

(National Fire Protection Association, 2007). 

The mutual aid agreement between behavioral

health treatment programs may also cover

procedures to be used to ensure client privacy

and confidentiality (e.g., as mandated by 42

Code of Federal Regulations [CFR] Part 2

[Confidentiality of Alcohol and Drug Abuse

Patient Records]; the Health Insurance

Portability and Accountability Act, which

establishes privacy rules for the protection 

of health and mental health information; the 

Health Information Technology for Economic

and Clinical Health Act; any applicable State

privacy regulations). 

Organizations with which information

about clients in substance abuse treatment 

may be exchanged in a disaster, but that 

are not providers of substance abuse

treatment services, should be asked to sign

a qualified service organization agreement

(QSOA), as required under 42 CFR Part 2.

Such organizations may include voluntary

organizations, local emergency responder

organizations, and alternate service providers

(e.g., drug testing providers). 

Appendix F includes a sample MOA used by

OTPs in King County, WA. Other programs

can use it as a template or can adapt it, as

needed. Worksheet B6 (in Appendix B) can

be used to create a record of all completed

agreements. The disaster planning team can

consult with its State disaster behavioral 

health coordinator for advice on drawing up

an MOA, including mutual aid agreements

and QSOAs. Because of the legal implications,

programs are advised to consult an attorney

when negotiating such agreements. 

Exhibit 3-6. Staff Issues To Consider in Mutual Aid Agreements 

Agreements to provide mutual aid for staffing assistance may be helpful, but the ramifications of such 

efforts are best explored in detail long before any disaster occurs. An administrator at a program that 

experienced an influx of displaced clients after Hurricane Katrina felt that having more staff members 

would not have helped. He explained, “We have a limit of space, and we knew what would have to be 

done . . . . If you weren’t already working here and [didn’t know] what needed to be done, you’d have 

to be trained and we didn’t have time to train.” 

An administrator at another program affected by the hurricane was part of a network of clinics and 

requested staff assistance from an affiliate. The greatest challenge, he reported, was finding housing for the 

guest workers. Three people stayed with the administrator and his family at their small home, and others 

stayed with another staff member. “We put them in our own houses and fed them and brought them to 

work with us. It was a very difficult time.” Similar challenges occurred at other programs. One provider, for 

more than a month, housed several medical volunteers in a motorhome parked outside his house. 

Source: Podus et al. (no date). 

30 
31 

Chapter 3―Preparing for Disaster

The Emergency Management Assistance 

Compact (EMAC) is a national disaster relief 

compact that facilitates the transfer (within 

or across States) of personnel, equipment, 

commodities, and services to affected localities. 

All 50 States, the District of Columbia, Puerto 

Rico, Guam, and the U.S. Virgin Islands are 

EMAC members. Liability, cost responsibilities, 

credentialing, licensing, and certification issues 

are resolved in advance through the EMAC 

compact. In a disaster, the behavioral health 

treatment program would route or receive 

resource requests through the State emergency 

management agency. Information on EMAC is 

available at http://www.emacweb.org. 

Designate Personnel To Assume 

Command for Incident Response 

Federal guidelines for disaster planning

suggest that organizations follow a

management approach called the Incident

Command System (ICS; Federal Emergency

Management Agency [FEMA], 2007b), which

allows for flexible, appropriate response to any

kind and size of incident and which provides

common terminology for use by all responders

so that they clearly communicate with each

other. As part of the ICS, each organization

names its leaders for disaster response who,

in a large-scale incident, can readily integrate 

into the hierarchy of the whole community’s

disaster response leadership. 

In the ICS hierarchy, the leader of an

organization is referred to as the Agency 

Executive. When a disaster occurs and the 

behavioral health treatment program’s

Agency Executive activates its disaster plan,

he or she appoints an Incident Commander. 

Typically, the Agency Executive delegates the

Incident Commander role; however, in some 

circumstances the Agency Executive may

double as Incident Commander, for example,

if the program has a small staff or if the

effects of the disaster are relatively limited. 

During the disaster and in its aftermath,

the Agency Executive focuses on the

organization’s essential functions, while the

Incident Commander takes charge of disaster

response. The latter independently manages

response activities (e.g., evacuating the

premises, coordinating with rescue workers,

assessing damage, arranging for temporary

quarters and coordinating transportation to

that site, contracting for supplies or repairs)

and periodically communicates incident

status to the Agency Executive. 

Disaster planning teams are encouraged to

assign other incident response positions in

accordance with ICS (FEMA, 2007b). The ICS

structure is illustrated in Exhibit 3-7. 

Exhibit 3-7. Incident Command System 

Agency Executive Incident Commander 

Liaison Officer Safety Officer 

Public Information 

Officer 

Planning/ 

Intelligence Team Logistics Team Finance/ Administration Team Operations Team 

Source: FEMA (2007b). 
Disaster Planning Handbook for Behavioral Health Treatment Programs

The position of Incident Commander is the

only one that must be filled when the disaster

plan is activated (FEMA, 2007b). If the

incident is small in scope or short lived, the

Incident Commander may choose to retain

all responsibility for disaster response. If the

incident is larger or expanding, the Incident

Commander may assign duties to other

command officers, if they have been appointed

(e.g., Liaison, Public Information, Safety). 

The disaster planning team should designate

one or more backups for each ICS position

in case the primary designee is unavailable

when a disaster occurs or needs to be relieved 

during the disaster response. Large programs

operating in a disaster with significant

impact may also organize teams for response,

as recommended for an ICS (Operations,

Planning/Intelligence, Logistics, and Finance/

Administration). 

For the behavioral health treatment program,

an advantage of organizing personnel into

an ICS is that the unambiguous hierarchy

provides for effective management and

accountability. The size of the responding

group can be changed, depending on

immediate needs and the scope and duration

of the incident. Another advantage is that

personnel can be readily integrated into the

teams of other organizations involved in

disaster response. 

External response groups (e.g., those headed

by a county emergency manager or fire

department) will be organized using the

ICS structure. For example, the Operations

Team of an external response group might be

responsible for conducting search and rescue

or fire suppression. The behavioral health

treatment program’s key personnel should

be familiar with the names and functions of 

ICS positions, in case they are called on to

interact with external response groups that

are organized in this manner. 

To clarify how ICS works, a hypothetical

example is presented in Exhibit 3-8. 

Worksheet B7 (in Appendix B) can be used

to assign staff members to ICS positions. 

Online courses on ICS, offered through the 

Independent Study Program of the Emergency 

Management Institute, FEMA, can be accessed 

at http://training.fema.gov/IS. 

Prepare Clients for a Disaster 

Psychological distress, severe depression,

somatic symptoms, posttraumatic stress

disorder (PTSD), and changes in the amount

and type of substance use—these are some of

the reactions individuals may have during or

following disaster. Program clients will vary in

their resilience, depending on many interacting

factors, including an individual’s social

supports, previous experience with trauma,

preexisting medical and behavioral health

status, gender, ethnicity, and socioeconomic

status (Cepeda, Saint Onge, Kaplan, &

Valdez, 2010; Cepeda, Valdez, Kaplan, & Hill,

2010; Cerdá, Tracy, & Galea, 2011; Laditka,

Murray, & Laditka, 2010; Picou & Hudson,

2010; Rhodes et al., 2010; Zwiebach, Rhodes, & 

Roemer, 2010). People with health issues may

respond more slowly in disaster situations and

may be unable to respond adequately, placing

them at greater risk. They also may be more

susceptible to disaster effects (e.g., extreme

weather conditions or limited food and water 

supplies) (Bethel, Foreman, & Burke, 2011).

Young people are at particular risk for negative

mental health effects subsequent to disaster

(Mace et al., 2010b; Murray, 2010). 

Specific disaster-related factors (e.g.,

the impact in terms of injury, loss, or

displacement; the passage of time since the

disaster) will influence the behavioral health

issue that predominates among a program’s

clientele. For example, the predominant

behavioral health issue for 182 survivors of 

the Oklahoma City bombing 6 months after

the incident was symptoms of PTSD; for 421

evacuees 2 weeks after Hurricane Katrina, 

the issues were preexisting, chronic mental

and substance use disorders (North, 2010). 

Even though resilience and need after a

disaster will vary and cannot be fully predicted, 

32 
33 

Chapter 3―Preparing for Disaster

all clients can benefit from preparation.

People are more intentional about preparing

for disaster when they consider the basic

service interruptions that could occur (Martel

& Mueller, 2011). For this reason, programs

should be explicit in describing how a disaster

can affect the community at large (e.g.,

electrical outages, interruptions in water

service) and the behavioral health treatment

program specifically (e.g., closures, reductions

in services, services provided at an alternate

facility). Programs can educate clients about

what to do to take care of their own needs to the 

extent possible in a disaster (see Emergency

Planning for Staff and Clients, in Appendix D). 

Disaster preparedness resources for individuals 

and families are available from the National 

Child Traumatic Stress Network. These 

include family preparedness tips and family 

preparedness wallet cards (for recording 

emergency contact information) in English and 

several other languages. They can be accessed 

at http://www.nctsn.org/resources/publicawareness/national-preparedness-month#q3. 

Exhibit 3-8. Hypothetical Example of an ICS in Action 

An earthquake occurs at 1 a.m., damaging a two-story residential treatment center located on a 

major urban thoroughfare. The senior person on staff is the night shift clinical nurse supervisor. Both 

the executive director and security officer are at home when the earthquake occurs, and, because of 

highway damage, getting to the facility is difficult. Phone and Internet systems are out of service where 

the treatment program is located. 

The clinical nurse supervisor is aware that although he is third in line to fill the Incident Commander 

role (behind the executive director and security officer), he must assume the role because the other two 

persons are not onsite. As Incident Commander, he assigns the two custodians on duty to assess the 

condition of the building and report back. They report structural damage, so the Incident Commander 

orders an evacuation of the building to a safe location—a city park two blocks away. 

The Incident Commander assigns the role of Safety Officer to a nurse on duty. Using staff and patient 

rosters, the Safety Officer makes sure that everyone leaves the building safely. As the patient roster 

indicates, two patients on the upper floor have physical disabilities and cannot use the stairs. It is 

inadvisable to use an elevator after an earthquake, so the Incident Commander organizes staff members 

to evacuate those patients using evacuation slings. Before permitting this evacuation to proceed, the 

Safety Officer ensures that the evacuation slings are in good condition; that staff members are trained, 

licensed, and physically able to use the slings; and that the evacuation route is safe. 

Shortly thereafter, a fire breaks out on the block, and several fire trucks and ambulances arrive. The head 

of the fire squad assumes the role of Incident Commander for the fire incident. The treatment program’s 

clinical nurse supervisor maintains the role of Incident Commander for the residential treatment center 

and takes on the role of Liaison Officer to coordinate with the emergency responders. He provides the 

fire squad’s Liaison Officer with information about the patients under his care, including confirmation 

that the building was evacuated and that the residents have been congregated in a safe location 

outside the fire zone. 

The treatment program’s security officer arrives an hour later, and, after being briefed, she assumes the 

Incident Commander role from the clinical nurse supervisor. She directs the clinical nurse supervisor to 

retain the role of Liaison Officer, because communication between the treatment center and the fire 

department continues to be important. 

Based on plans established earlier, the Incident Commander manages the treatment program’s disaster 

response. She immediately arranges for patients to be moved to a residential center unaffected by the 

earthquake and coordinates the reassignment of staff to the temporary location and the notification of 

families with updated information and the status of their family members. The next day, conferring with 

the executive director (the Agency Executive, in ICS parlance), she sets in motion the inspections and 

repairs needed to restore onsite clinical services. 
Disaster Planning Handbook for Behavioral Health Treatment Programs

All clients need to know how they will be

informed if the program is closed or has

changed its hours of operation and what they

should do if the program closes or is providing 

services in another location. They also need

to know what they should do if they cannot

access prevention, treatment, or recovery

services for several days or if they begin to

experience a physical or behavioral health

crisis. The program can consider issuing

clients maps that contain directions to the

facility using different routes and modes of

transportation. The map also can indicate

routes to the alternate care facility clients

are advised to use if the program is closed

(based on a previously developed MOA).

Maps should be in an accessible format for

the client population (e.g., in large type, in

Braille, in languages other than English that

are prevalent in the community), and they

should contain street address, phone, email,

and Web site information. 

Clients can be informed of the items they

should bring to an alternate site. These may

include the name of their home behavioral 

health treatment program and treating

physician, an ID card issued by the program

or other form of personal photo ID (e.g., a

driver’s license), and medications and dosage

information (see Chapter 5). 

Ideally, the program discusses with clients

the need for disaster preparedness at

intake and at regular intervals during their

treatment involvement (e.g., by reviewing

procedures at the start of each hurricane

season). Counselors can provide clients

with instructions for self-care related to 

their behavioral health disorder treatment 

(on a laminated wallet-sized card, for

example). They also can direct clients to

disaster preparedness planning information

for individuals and families. The program

can prepare in advance a recorded phone

message, to be used in a disaster situation,

providing instructions to clients on what to

do if the program is closed. These emergency

instructions also can be readied for posting

on the facility’s front door and to social media

Web pages. 

Members of a client’s support network (e.g.,

family, partner) also need to be provided

with emergency instructions and should be

informed as soon as possible of unexpected

discharge, evacuation, or relocation. To

the extent possible, any evacuations or

relocations should be coordinated with the 

client’s support network so that the client

can be accompanied. Individuals to be

contacted in an emergency should be listed

in the client’s records, and appropriate

authorizations/releases should be in place. 

Programs can help clients prepare an

emergency health information card, which

lists the client’s special needs and provides

guidance to emergency responders on

appropriate methods for assisting the

person, communicating with the person, and

interpreting the person’s behavior. The card

allows for fast communication of pertinent

information to rescuers and personnel

working evacuation and shelter sites. 

The Independent Living Resource Center of 

San Francisco’s Web site contains a series of 

tip sheets on emergency preparedness for 

people with disabilities. These tip sheets can 

be accessed through their publications page 

at http://www.ilrcsf.org/access-resources/ 

publications/. 

Obtain Client Locator Information 

After a disaster, clients may be dispersed

from their regular residences and

surroundings. The program’s efforts to locate

clients after a disaster, and to reengage them

in services, can be facilitated by collecting

sufficient contact information at intake. 

The disaster planning team can work with

staff responsible for the program’s intake

form to ensure that sufficient emergency

contact information is collected and regularly

updated. 

Ideally, the intake form requests the

following: client contact information (e.g.,

address, landline, cell phone, email, social 

34 
Chapter 3―Preparing for Disaster

networking Web sites); emergency contact

information for one or more relatives, friends, 

or professionals with whom the client

interacts (e.g., employer, probation officer,

mutual-help group sponsor); and an outof-area point of contact. Locations that the

client frequents can be noted on the form,

if this information is available. A physical

description or photo of the client also can be

helpful. The form should have a place for the

client’s signature indicating that release of

the information is permitted for purposes

of tracking the client for reengagement.

Counselors should explain the intent behind

the form. This discussion can be used as 

an opportunity for introducing the topic of

disaster preparedness. 

Client locator forms are used by researchers 

to find subjects from a study for follow-up 

interviews. Such forms can be used as models 

by the behavioral health treatment program 

wanting to supplement its intake form with 

enough information to find clients who 

may be displaced in a disaster situation. An 

example of a client locator form is provided 

in Staying in Touch: A Fieldwork Manual of 

Tracking Procedures for Locating Substance 

Abusers in Follow-up Studies, published by the 

University of California, Los Angeles Integrated 

Substance Abuse Programs. The manual 

can be found at http://www.uclaisap.org/ 

trackingmanual/manual/Tracking-Manual.pdf. 

Encourage Staff To Make Plans for 

Personal Preparedness 

Staff members should be strongly encouraged

to develop emergency plans for their own

households. Having personal plans in place

has personal benefits for staff members and

their families and increases the likelihood 

that they will be available to respond to their

professional duties. 

Information on personal preparedness is 

available at a FEMA-sponsored Web site, 

http://www.ready.gov. 

The American Red Cross has developed a series 

of mobile apps that provide users with real-time 

information on what to do before, during, and 

after emergencies. They are available at http:// 

www.redcross.org//prepare/mobile-apps. 

Prepare Staff for Supporting 

Clients in Disaster 

The disaster planning team can arrange for

staff trainings that address disaster-related

behavioral health topics (e.g., recognizing

symptoms of psychological trauma in clients,

referring such clients to psychological first

aid services provided in the community,

supporting clients’ coping skills, conducting

trauma-informed therapy). Training may

be valuable not only for direct service staff

members, but also for administrative staff 

members, particularly those who answer

phones or greet clients at the entrance. An

ideal approach is to provide live, in-person

disaster training, in which the trainers can

focus on the roles of the participants and how

disaster may affect their jobs. Live training

also allows for discussion of topics that are of

particular concern to staff. Live training can

be supplemented by further online training

as appropriate (such as for yearly refresher

training). 

The Substance Abuse and Mental Health 

Services Administration’s (SAMHSA) Disaster 

Behavioral Health Information Series provides 

themed resource collections and toolkits 

pertinent to the disaster behavioral health 

field on topics such as psychological first aid, 

resilience, and stress management. They are 

available at http://www.samhsa.gov/dtac/dbhis/. 

Exhibit 3-9 provides psychological first

aid recommendations for first responders

(emergency and disaster response workers).

These recommendations may be shared with

behavioral health treatment program staff

members so that they are sensitive in their

initial contacts with clients after a disaster. 

35 
Disaster Planning Handbook for Behavioral Health Treatment Programs

Programs may wish to provide training to

clients to support peers in disaster

preparedness and in coping after disaster.

Some programs already use peer

professionals as part of their staff. Having

these individuals trained as members of the 

disaster response team, or available to assist

other staff in working with clients under

disaster conditions, provides an additional

resource for the program. 

Exhibit 3-9. Psychological First Aid 

Promote Safety: 

• Help people obtain emergency medical attention. 

• Help people meet basic needs for food and shelter. 

• Provide repeated, simple, and accurate information on how to meet these basic needs. 

Promote Calm: 

• Listen to people who wish to share their stories and emotions; remember that there is no right or 

wrong way to feel. 

• Be friendly and compassionate even if people are being difficult. 

• Offer accurate information about the disaster or trauma, and the relief efforts underway, to help 

victims understand the situation. 

Promote Connectedness: 

• Help people contact friends and loved ones. 

• Keep families together. Keep children with parents or other close relatives whenever possible. 

Promote Self-Efficacy: 

• Give practical suggestions that steer people toward helping themselves. 

• Engage people in meeting their own needs. 

Promote Help: 

• Find out the types and locations of government and nongovernment services and direct people to 

those services that are available. 

• When they express fear or worry, remind people (if you know) that more help and services are on 

the way. 

Do Not: 

• Force people to share their stories with you, especially very personal details. 

• Give simple reassurances like “everything will be okay” or “at least you survived.” 

• Tell people what you think they should be feeling or thinking or how they should have acted earlier. 

• Tell people why you think they have suffered by alluding to victims’ personal behaviors or beliefs. 

• Make promises that may not be kept. 

• Criticize existing services or relief activities in front of people in need of these services. 

Excerpted and adapted from SAMHSA (2005). 

36 
37 

Chapter 3―Preparing for Disaster

Information on training individuals with 

behavioral health disorders to provide peer 

support in and after a disaster is available 

from After the Crisis, a collaborative initiative 

between the National GAINS Center and the 

National Center for Trauma Informed Care and 

supported in part by SAMHSA. Information is 

available at http://gainscenter.samhsa.gov/atc. 

Staff may need to be prepared to give extra

support to certain groups of clients. These

groups, and the support that can be provided to

them, are detailed in the following paragraphs. 

Clients With Cognitive or Intellectual 

Disabilities 

Disaster preparedness education may need

to be simplified, provided through multiple

means, and repeated frequently. Clients

may need individual support when being

unexpectedly discharged, evacuated, or

transferred. Counselors also may need to work

with surrogate decisionmakers (e.g., a client’s

parent, other family member, guardian) to

plan and prepare clients for disasters. The

program can recommend clients with cognitive

or intellectual disabilities for priority disaster

case management by organizations that

provide that service (see Prepare To Connect

Clients to Disaster Case Management, below). 

Clients With Mobility Issues 

Clients may need special help and assistive

devices during building evacuation and

relocation, especially if the program is

located on upper floors of a building. Such

clients should be informed in advance of 

the evacuation methods that will be used 

to help them exit the premises (e.g., the use

of wheelchairs, gurneys, evacuation slings,

two-person hand carrying). Regular safetyrelated drills (e.g., for response to fire, bomb

threat, chemical hazard; loading people in

wheelchairs onto buses) provide opportunities

for clients and staff to become familiar with 

any special evacuation plans and methods.

Such drills are required by all licensing

and credentialing bodies. Though staff (and 

clients) may find them inconvenient, they

are important practice for evacuation in an

emergency, and especially for safe and efficient

evacuation of clients with mobility issues. 

Clients With Limited Literacy, Limited 

English-Language Proficiency, or Cultural 

Differences 

Disaster-related messages (e.g., evacuation

instructions, phone and Web site messages

about facility closures, instructions to clients

on accessing treatment during a disaster)

should be tested with clients who have 

limited reading ability. Messages should be

provided in the client’s primary language,

if possible, and in a manner appropriate to

the client’s culture. Program staff should

be instructed not to assume that clients are 

literate and can follow written directions. 

Key messages should be presented orally and

frequently. The disaster planning team may

wish to consult with community members

who have expertise in the cultural attitudes

and languages of clients to ensure that

disaster planning concepts and instructions

are effectively communicated. Interpreters

can be included in disaster planning and

exercises. Disaster-related communications 

with clients may be enhanced when staff

members have received training in cultural

competency. Exhibit 3-10 illustrates the

challenges in disaster preparation for clients

with limited English proficiency. 

Developing Cultural Competence in Disaster 

Mental Health Programs is a SAMHSApublished guide that can help States and 

communities plan, design, and implement 

culturally competent disaster mental health 

services for survivors of natural and humancaused disasters of all scales. The guide is 

one component of the SAMHSA Disaster Kit, 

which includes a range of materials for disaster 

recovery workers. Other items in the kit include 

brochures for distribution to the general public 

and guidance on dealing with the stress of 

disaster response. The kit can be ordered or 

downloaded from SAMHSA at http://store. 

samhsa.gov/product/SMA11-DISASTER. 
Disaster Planning Handbook for Behavioral Health Treatment Programs

Exhibit 3-10. Challenges in Disaster Preparedness for Clients With Limited 


English Proficiency
 

Shiu-Thornton, Balabis, Senturia, Tamayo, and Oberle (2007) studied disaster preparedness for clients 

with limited English proficiency by interviewing 38 medical interpreters representing 30 languages. The 

researchers found that few interpreters had training in disaster preparedness or direct experience with 

interpreting in disaster situations. Furthermore, many cultural groups do not discuss the potential for 

disasters or engage in discussions concerning disaster preparedness, and some cultural groups have 

beliefs that are dissonant with the concept of preparedness. Disaster may be a taboo topic, group 

members may believe that events are predestined or in the hands of fate, or they may believe that the 

United States is a safe haven where disasters do not occur. 

Clients Who Are at Risk of Acute Episodes 

of Psychiatric Illness 

A psychiatric advance directive (PAD) may

provide some measure of protection for clients

who could become destabilized in a disaster. 

A PAD is a legal document, accepted in

most States, through which an individual

can indicate preferences and instructions

for treatment of behavioral health disorders 

at times when he or she is not competent

to express his or her own wishes. Through

a PAD, individuals can assign power of

attorney to the person of their choice to

make decisions about care when they

themselves are incapacitated. PADs can

include instructions on refusal or consent 

regarding hospital admission, particular

medications, and treatments. PADs also can 

contain other important information, such

as guidance about the type of care that could

help the individual avoid hospitalization (or,

if hospitalization is needed, accommodate

to it). A PAD is used to guide healthcare

decisions only when an authority (one or

more physicians or a judge, depending on

the State) determines that the individual

lacks capacity to make decisions. Treatment

program counselors can assist clients in

understanding PADs and drafting PADs that

are accepted in their respective State. They

also can assist clients in distributing copies

of their PADs to their treatment program,

medical doctor, local hospital (for filing in

their medical records or inclusion in their 

electronic health record), and reliable friends

or family members. Clients also can be 

advised to keep a copy on their person when

relocating in disaster. 

The National Resource Center on Psychiatric 

Advance Directives provides information about 

PADs. How-to instructions, State requirements, 

and other forms can be downloaded from 

http://www.nrc-pad.org. 

Children and Youth 

Young people’s positive coping can be

promoted by sharing age-appropriate

information about disasters, before they

occur (Murray, 2010). The information can

include what to expect before, during, and

after a disaster incident. The opportunity to

ask questions is also important. Families of

young clients can be encouraged to develop

a family response plan, to include younger

family members in making preparations

(e.g., in assembling the family’s go kit),

and to periodically review and discuss

their response plan with family members.

Parents and caregivers of children and

youth can be directed to resources that will

help them develop a family response plan

and prepare their young family members

(see Emergency Planning for Staff and

Clients, in Appendix D). 

As previously stated, any evacuations or

relocations should be coordinated with the 

client’s support network so that families

and significant others become aware of

these plans and have a way to contact

the client once they are relocated. To the 

38 
39 

Chapter 3―Preparing for Disaster

extent possible, family members should be

kept continuously informed of changing

circumstances. Young people in residential

treatment, along with their families, may

need extra help with any transitions of care

to alternate providers or locations, to reunite

as needed, and to handle the psychological

effects of the disaster. Efforts should be 

made to provide youth-oriented treatment

services and supports at any new location

(e.g., separate group meetings for youth

and connecting relocated young clients with

clinicians who have training and experience

working with that age population). Youth

may need assistance transitioning to a new

school if the disaster has forced a transfer, 

and they may need activities to keep them

safely occupied if schools are closed. Despite

changed conditions, effort should be made to

promote an atmosphere of normalcy (Mace et

al., 2010a). 

Pregnant Clients or Clients With 

Dependents 

Pregnant clients will need to be closely

monitored to ensure that they can maintain

a healthy pregnancy despite disaster

conditions; they may need extra counseling

on disaster-related medical treatment that 

best protects them and their fetuses (see

also Exhibit 6-1, Pregnant Women at Special

Risk From Influenza, in Chapter 6). Patients

who have children with them in residential 

treatment and who are relocated will need 

to be transferred to like facilities that enable 

the children to stay with them. The facilities

will need to be ones that can provide a safe

and secure environment for those children, 

with access to child care or schools as 

appropriate. Some clients may be unwilling

to disclose their behavioral health disorder 

treatment needs to care providers at a new

location for fear of losing custody. These

clients need to be educated in advance about 

how to advocate for their needs without 

risking custody. 

Clients Who Are Experiencing 

Homelessness 

People who do not have a residence are

less able to prepare for emergency (e.g.,

stockpile supplies, identify a safe part of

a house in which to shelter). In addition,

people without a home may have limited

access to electronic means of communication 

(e.g., TV, radio, Internet) and thus may be

slower to learn about emergency warnings

and calls for evacuation. Furthermore, for a 

variety of reasons, people who do not have a

home may have difficulty or concerns about

entering shelters, and they also may have

more difficulty transitioning out of shelters,

especially if the locations where they formerly

took refuge (such as an encampment) are

no longer habitable (Edgington, 2009).

Behavioral health treatment programs can

support clients known to be experiencing

homelessness by making sure they receive

disaster planning education and aids

(e.g., emergency kits, emergency health

information cards). In addition, the program

can request that its outreach workers be

included in the local community’s emergency

notification systems so that they can be

mobilized in a timely manner to communicate

emergency situations to clients who are

experiencing homelessness. The program also

can recommend clients who are experiencing

homelessness for priority disaster case

management by organizations that provide

that service (see Prepare To Connect Clients

to Disaster Case Management, below). 

Older Clients 

Factors that can cause some older clients to 

be particularly vulnerable in disaster include

physical frailty, chronic illness, cognitive

impairment (including impaired capacity to

make decisions and execute tasks), mobility

and sensory issues, reliance on devices

such as hearing aids and glasses, limited

transportation options, and susceptibility

to exploitation and abuse (Cloyd & Dyer,

2010). Other age-related factors that may

interfere with clients obtaining necessary

aid include a preference for self-reliance, 
Disaster Planning Handbook for Behavioral Health Treatment Programs

difficulties navigating bureaucratic recovery

systems (especially those that require

online applications and other computerrelated tasks), and concerns about loss of

entitlements. Among older adults, disaster

response may manifest itself in physical

rather than psychological distress (Sakauye

et al., 2009). Staff training on the particular

needs of older clients, as well as coordination 

with community services for older adults, can

facilitate support to this client population in

disaster. 

Clients on Medications 

Assisting clients who are on prescription

medications is covered in Chapter 5. 

Prepare To Connect Clients to 

Disaster Case Management 

People affected by disaster often face a

“challenging service labyrinth” as they seek

to recover housing and other resources

(Stough et al., 2010). The process can be

especially complex and difficult for people

with psychiatric disabilities who, in past

disasters, have faced discrimination with 

regard to evacuation, emergency shelters,

and relief services (National Council on

Disability, 2006). 

Some jurisdictions have plans in place

for providing citizens with disaster case

management (i.e., personal assistance in

navigating recovery services). In an event

that is declared a major disaster by the

President of the United States and that 

meets other criteria, the Federal Disaster 

Case Management (DCM) Program may

rapidly allocate funding for disaster

case management assistance to disaster

survivors. Funds are administered by the

Administration for Children and Families, 

U.S. Department of Health and Human

Services, and the case management services

are offered via existing State, local, and

voluntary programs (Lavin & Menifee, 2009).

“Mental health issues” and “medication 

management” are specifically cited by the 

DCM Program’s guidelines as among the

needs that can be addressed by disaster case

management services. 

A representative of the behavioral health

treatment program’s disaster planning team

can contact the local office of emergency

management to determine whether the

community has a disaster case management

program equipped to provide services to

clients with behavioral health issues and, if 

so, how to refer clients to it. In addition, the 

program can seek to work with Voluntary

Organizations Active in Disaster (VOADs)

whose case managers have expertise with

the issues of its clientele (e.g., issues related

to disabilities or mental or substance use 

disorders). 

The disaster planning team may want to

work with its program’s management to

train counselors in providing disaster-specific

case management and to develop a list of

community resources to which counselors can

refer clients for disaster recovery support.

Alternatively, the team can work with

program management to develop policies for

identifying and prioritizing clients for referral

to disaster case management, if such services

will be available from other community

providers. 

Ensure Counselor Access 

to Shelters 

During Hurricane Katrina, situations

occurred in which professional counselors

and members of mutual-help groups (e.g.,

Narcotics Anonymous, Alcoholics Anonymous) 

were prohibited from entering shelters to

assist evacuees in need of behavioral health 

treatment services (SAMHSA, 2009). As a

result, Federal guidelines for emergency

shelters now call for the inclusion in planning

of people with mental health expertise as well

as input from people with disabilities, access

issues, or other functional needs (FEMA,

2010b). 

40 
41 

Chapter 3―Preparing for Disaster

The disaster planning team leader can work

to arrange for the program’s counselors and

recovery advocates to participate in local

shelter planning and to become credentialed

for shelter staffing. The disaster planning

team also can encourage program staff

members and community recovery advocates

to take the advanced training and obtain the

credentialing that would allow them inside

shelters and at evacuation departure and

receiving sites. A working relationship with

the American Red Cross and other VOADs, 

through the community’s emergency planning

committee, can facilitate these arrangements

(see Chapter 2). 

Prepare for Financial Resiliency 

A study of 15 substance abuse treatment

programs affected by the September 11,

2001, attacks in New York City found that

several programs experienced financial

losses following the disaster (Dewart, Frank,

Schmeidler, Robertson, & Demirjian, 2003).

Outpatient programs were particularly

affected because of declines in client 

attendance and retention. Of the 15 programs

surveyed, the 3 that closed on the day of

the attacks and in the days afterward were

outpatient treatment programs (not OTPs).

Fewer financial problems were experienced

by programs with substantial numbers

of clients on Medicaid or clients able to 

access emergency Medicaid. Programs that

provided outpatient counseling by telephone

as a substitute for in-person sessions

had mixed results in obtaining insurance

reimbursement. 

This experience suggests that behavioral

health treatment programs should consider

how they can support client retention through 

active outreach following a disaster. Program

staff members should become informed 

about procedures for enrolling clients in

Medicaid under emergency conditions, and

they should educate payers about modified

counseling services (e.g., telephone or Webbased counseling) that may be instituted in

disaster situations; this may help facilitate

reimbursement. Management can establish

a contingency or reserve fund or a line of

credit for unexpected cash flow issues (e.g.,

maintaining payroll for staff when billing is

disrupted). 

Programs also can make plans for

persevering through a period of low revenue

following a disaster (e.g., planning ahead for

emergency grant proposal writing, temporary

modification of fees, intensive marketing

and outreach, expansion into community

disaster-specific behavioral health response

and support activities, careful tracking and

documentation of services provided during

the disaster so that reimbursements are 

facilitated). 

Chapter 4—Continuity Planning
 

In This Chapter 

•	 Identify Essential Functions 

•	 Identify Essential Staff 

•	 Provide for Continuity of

Leadership 

•	 Arrange for Alternate

Facilities 

•	 Ensure Interoperable

Communications 

•	 Protect Vital Records and 

Databases 

•	 Develop Resources To Manage

Human Capital 

Worksheets (see Appendix B) 

•	 B8 Identify Essential

Functions 

•	 B9 Identify Essential Staff

Positions 

•	 B10 Essential Staff Roster 

•	 B11 Checklist for Continuity

Planning 

•	 B12 Requirements for

Alternate Facilities 

•	 B13 Alternate Facility

Arrangements by Disaster

Scenario 

•	 B14 Checklist for Relocation 

Planning 

•	 B15 Checklist for 

Maintaining Communications

With Essential Groups 

•	 B16 Checklist of Records 

and Databases To 

Ensure Interoperable

Communications 

•	 B17 Checklist for Protecting

Records and Databases 

•	 B18 Checklist for Managing

Human Capital 

This chapter addresses the tasks required to ensure

business continuity, commonly referred to as 

continuity of operations planning or COOP planning. 

A continuity plan can be included as a functional

annex to the basic plan. Chapter 5 provides additional

guidance on continuity planning for programs that

manage prescription medications for treatment of

behavioral health disorders. 

Identify Essential Functions 

To identify the program’s essential functions, the

disaster planning team first works with management

to inventory all functions performed at the facility.

From this comprehensive list, the team and

management work together to identify those functions

that are essential because they provide vital services

to clients; are required by regulation or law; are

required to maintain onsite safety for clients, family

members, and staff members; or are necessary for

the performance of other essential functions (Federal

Emergency Management Agency [FEMA], 2004). 

These essential functions should be prioritized by

potential consequences if the function is not performed

or is delayed. Exhibit 4-1 provides examples of

what a program might decide are its essential and

nonessential functions. (Note: Each program makes its

own determinations of what is essential.) Worksheet 

B8 (in Appendix B) can be used to help identify

essential functions. 

Exhibits 4-2 and 4-3 provide examples of programs

that worked to continue essential operations during

winter storms. 

Identify Essential Staff 

Once essential functions have been identified, the 

disaster planning team continues to work with

program management to identify the staff positions

required to perform those essential functions.

The team and management also work together to

identify the specific individuals who can serve in 

43 
Disaster Planning Handbook for Behavioral Health Treatment Programs

Exhibit 4-1. Examples of Essential and Nonessential Functions 

Program 

Type Essential Functions Nonessential Functions 

All Programs 

• Provide for the physical safety of all clients and visitors at the facility. 

• Provide behavioral health emergency services. 

• Conduct basic screening, intake, and discharge procedures. 

• Track clients affected by dispersal and evacuation to ensure they 

continue to receive needed behavioral health services. 

• Provide crisis and relapse prevention counseling; ensure that some 

support is available to clients. 

• Assist clients in accessing needed medications. 

• Conduct drug testing for mandated clients. 

• Adhere to applicable State licensing standards. 

• Maintain treatment and billing records in accordance with payer and 

regulatory requirements. 

• Document transfer of clients and their records to another provider. 

• Protect client rights and privacy, including the integrity of protected 

health information records. 

• As resources are available and based on mandates, provide disaster 

mental health services to the community as requested by the 

Emergency Operations Center or Emergency Support Function #8 

Coordinator. 

• Provide prevention guidance specific to the present disaster to 

reduce the likelihood of traumatic stress in the program’s clientele 

and other members of the local community.* 

• Perform 

extended intake 

and discharge 

procedures. 

• Conduct 

nonmandated 

drug testing. 

• Offer routine 

counseling and 

education. 

• Provide general 

mental and 

substance 

use disorder 

prevention 

services. 

Outpatient 

Treatment 

Programs 

• Assist with case management activities such as linking to resources, 

including helping clients obtain replacements or refills, as 

appropriate, for needed medications. 

• Provide crisis stabilization, crisis intervention, or other emergency 

services to outpatients. 

• Provide regular 

outpatient 

services. 

• Host onsite 

mutual-help 

group meetings. 

• Donate meeting 

space for 

community groups. 

Residential 

Treatment 

Programs 

• Provide residential care for patients who do not meet discharge criteria. 

• Stabilize patients undergoing nonmedical (social) detoxification 

(see section below for essential functions of a program providing 

medically managed detoxification). 

• Continue medications and supportive counseling to patients to 

prevent decompensation or escalation of symptoms of behavioral 

health disorders. 

• Coordinate or address transportation needs for accessing medical 

services. 

• Provide case management services, as appropriate, to move patients 

toward discharge readiness. 

• Provide residential 

care for patients 

who can be 

discharged. 

* Public messages in disaster should be coordinated with the Public Information Officer of the community’s Incident Command System 

(see Chapter 3). 

44 
Chapter 4—Continuity Planning

Exhibit 4-1. Examples of Essential and Nonessential Functions(continued) 

Program 

Type Essential Functions Nonessential Functions 

Medically 

Managed 

Detoxification 

Programs 

• Follow established medically managed detoxification protocols. 

• Medically stabilize patients; closely monitor patients’ withdrawal 

symptoms. 

• Transfer patients who require a higher level of medical care than the 

program can provide to an appropriate facility; provide residential 

care for patients who remain at the facility. 

• Medically detoxify 

patients who 

can be safely 

transferred to 

and detoxified in 

another setting. 

Opioid 

Treatment 

Programs 

(OTPs) 

• Confirm identities and dose information for patients receiving 

medication. 

• Provide or facilitate access to prescribed or dispensed medications 

(e.g., methadone, buprenorphine). 

• Provide case management to assist with medically appropriate 

transfer or discharge. 

• Provide other 

case management 

services beyond 

those determined 

essential. 

Exhibit 4-2. Essential Operations Continuity During a Winter Storm (Example 1) 

A major winter storm stranded residential program staff members in their homes and resulted in on-duty 

staff extending their shifts to nearly 72 hours. Travel was not advised, and access to the interstate highway 

was closed. Food was not an issue because the program had stored a 2-week supply of provisions. 

The program had recently purchased and implemented a Web-based client management system that 

clinical supervisory staff could access from home to create and modify treatment plans that could be 

implemented by clinical staff. This system allowed staff to document client progress and medical updates 

with no interruption to client services. 

During the storm, assigned therapy sessions had to be rescheduled or canceled because some therapists 

could not get to work. The onsite team had to be creative, and the program assumed a comfortable 

“retreat” atmosphere as the staff took this opportunity to work with clients more deeply on specific group 

topics. It was decided afterward to plan a series of mini retreat activities as “off-the-shelf” options, for use 

in future incidents when the program is short staffed because of emergency. 

Source: Michael Lynde, personal communication, May 3, 2010. 

Exhibit 4-3. Essential Operations Continuity During a Winter Storm (Example 2) 

An outpatient treatment facility was hit hard by an unexpected snow and ice storm. The emergency 

preparedness plan was initiated. A few staff members who had computer access at home worked 

throughout the day providing phone counseling and documenting those client services in the 

client record electronically. Phone services included triaging counseling emergencies, rescheduling 

appointments, and providing supportive recovery counseling to clients and family members, as well as 

counseling to relieve any mild anxiety caused by the storm. Client care continued throughout the storm. 

Source: Kathyleen M. Tomlin, personal communication, May 1, 2010. 

45 
Disaster Planning Handbook for Behavioral Health Treatment Programs

those positions. Such people must have

the knowledge, skills, and abilities for the

designated roles, as well as the required

certifications and licenses. Some personnel

may be able to assume the essential duties

of multiple staff positions. The credentials

and State licenses of essential staff should 

be scanned and saved electronically, in case

this documentation is needed at an alternate 

location or receiving facility (see Protect

Vital Records and Databases, later in this 

chapter). Essential function status should be

included in job descriptions and expectations

communicated to employees. 

In a disaster situation, only essential staff

members would report for work onsite or in

the new location (if the facility has moved);

other available staff members would be 

directed either to stay at home or to be

available to work on a rotating schedule.

The goal is to assemble a roster of the

minimum number of people who together

can perform all essential functions. Multiple

backups for all positions should be assigned

in case the designees are unavailable or

have been called away to serve in behavioral

health response efforts. Worksheets B9 

and B10 (in Appendix B) can be used to

complete this task. 

To facilitate the development of an essential

staff roster, the team can ask the program’s

management to prepare staff members for

the possibility that, in a disaster situation,

they will have to perform additional duties

or work under changed schedules. Staff

members need to be briefed regarding the

scope of their responsibilities as outlined in

the disaster plan, and they need to be willing

to carry out those duties (e.g., a mental

health services provider may be asked to

pass out blankets and water bottles when

speaking to people who have been evacuated

into a shelter). Expectations related to

reporting to work during a disaster can

be clearly stated in policy, included in job

staff descriptions, and covered in annual

reviews. Staff members also can be assisted 

in creating plans, in advance, for dependent 

care so that they can report as needed for

duty. 

Management can work with staff members

who usually perform an essential function to

develop a written plan for maintaining that

function in a disaster situation. The planning

team can assemble these plans together

into the continuity plan functional annex. 

Worksheet B11 (in Appendix B) lists some

questions to be addressed as the team drafts

the continuity plan. 

Provide for Continuity 

of Leadership 

Leadership is essential in a disaster, so

alternate leaders need to be identified in 

advance for situations in which personnel who

normally exercise authority are incapacitated

or unavailable. For each such position,

management must approve the order of

succession and the delegation of authority. 

Order of Succession 

An order of succession officially passes

authority from one person to another.

Depending on the size of the facility and staff,

several successors may be named for each

position; multiple successors are especially

important for the pandemic influenza

scenario (see Chapter 6). If possible, the

order of succession should include successors 

who work at different facilities in the event 

all leaders at one facility are incapacitated.

Examples of order of succession for leadership

positions at a behavioral health treatment

program are provided in Exhibit 4-4. 

Delegation of Authority 

A delegation of authority describes the

permissible range of actions for each

leadership successor. The scope of authority

can be determined in advance for each named 

successor, based on his or her qualifications.

For example, if the executive director is not

on duty when a disaster occurs that calls

for immediate evacuation, a successor may 

46 
Chapter 4—Continuity Planning

 

 

Exhibit 4-4. Examples of Order of Succession at a Behavioral Health Treatment Program 

Leadership Position Example Order of Succession 

Executive Director/ 

Administrator 

1. Assistant director 

2. Clinical director 

3. Clinical nurse supervisor 

Clinical Director 

1. Clinical nurse supervisor 

2. Clinical nurse 

3. Senior licensed counselor or program manager 

Medical Director or 

Chief Psychiatrist 

1. Staff physician 

2. Advanced registered nurse practitioner (or other staff member with 

independent prescriptive authority) 

3. Certified physician assistant (or other staff member with independent 

prescriptive authority) 

assume authority to make decisions about the

move and, through prior arrangement, have

the authority to expend funds for transport.

Authority can be limited so that the

successor cannot make decisions about longrange matters. Once the executive director

resumes leadership, the successor’s delegated

authority is terminated. 

Arrange for Alternate Facilities 

The program’s disaster planning team can

research several options for continuing

essential operations elsewhere. These options

would be considered by leadership, and

the program director could authorize them

through Memoranda of Agreement with

alternate facilities. When a disaster occurs, 

a displaced program can move to the most

practical prearranged alternate facility,

given the circumstance (e.g., another space

within the building, another location of the

organization, space that is borrowed from

or shared with another organization in the

community, a site that is miles away or out of

State). 

The team should evaluate alternate facilities 

and suggest to leadership multiple options.

For each option, the team should consider

whether the prospective alternate facility is

located at a safe distance from the area— 

such that it would not be compromised by

the hazard that forces relocation; can be 

made operational in 12 hours or less; and has 

sufficient space, equipment, supplies, and

support services so that staff can perform

essential functions (FEMA, 2007c). Other

considerations include whether the proposed

facility has the necessary compatible

communications and computer systems

infrastructures to maintain essential services 

and is capable of meeting food, lodging,

health, sanitation, and security needs of

essential staff and clients either onsite or 

nearby. Some programs may already have

offsite hosting of software supporting various

functions, including electronic records. This

may provide an advantage in the case where

relocation of these functions is necessary. 

Each disaster planning team makes its

own determination of criteria for alternate 

facilities. For example, in addition to meeting

the criteria identified above, the team may

look for an alternate facility that is licensed

by the State authority, as required (e.g., for

an alternate residential, opioid dependence,

or child and adolescent treatment program).

Another feature the team may seek is space

that can be configured for providing essential

services (e.g., a client waiting room, private

rooms for counseling, large space for group

therapy) and that has necessary furnishings

(e.g., beds for residential services, tables

for serving meals, chairs for group rooms,

secured storage area such as lockable file

cabinets). Other features to consider are

whether the alternate facility is physically

accessible under Americans with Disabilities 

Act of 1990 requirements, is affordable (in 

47 
Disaster Planning Handbook for Behavioral Health Treatment Programs

terms of reserving in advance and using

the space), and meets security needs (e.g.,

provides secure space for storing medication,

records, and drug testing specimens). A final

consideration is whether the alternate facility

is appropriate for the population being served

(e.g., youth, women with young children). 

Worksheet B12 (in Appendix B) can be

used to collect data necessary to evaluate

prospective alternate facilities. Worksheet 

B13 (in Appendix B) can be used for recording

information about the facilities that are most 

appropriate for internal, local, regional, or

national disasters. 

The program has several options when

arranging for alternate facilities. It can

negotiate with another behavioral health

treatment program to provide space for each

other as necessary. This approach can be

practical because such programs often have

similar infrastructures. These sorts of mutually

beneficial arrangements are best arranged

in advance and in writing (see Negotiate

Memoranda of Agreement, in Chapter 3).

Alternatively, the program can arrange

to use space at another type of healthcare

facility (e.g., nursing home, hospital), or it can

negotiate for space at a non-healthcare-related

facility (e.g., college dormitory, sports complex,

motel, community-based facility). 

Essential services may need to be divided

among more than one alternate site, if no

single site meets all requirements. A situation

may arise in which no alternate location is

available or staff members are unavailable 

to work at or reach the alternate location. 

To prepare for this contingency, the disaster

plan should include a section on temporarily

transferring clients to another program where

they can be treated as guest clients. Advance

arrangements are needed, especially if the

plan will require that clients be dispersed

among multiple programs (see Prepare for

Transfers of Patients, in Chapter 5). 

The disaster plan needs to account for situations

when relocation will occur on short notice, such 

as when the facility has been compromised 

or the entire community has been ordered to 

evacuate. Worksheet B14 (in Appendix B)

includes a checklist for relocation planning. 

Another task of the team is to explore, and

have approved by the program director

or designee, standby contracts for critical

equipment and quantities of supplies that

would be needed at an alternate location 

(e.g., generators, tents, cleaning supplies

or services). For residential programs,

standby contracts may be needed for camp

beds, bedding supplies, and food supplies or

services. These contracts become effective only

if necessary following a disaster and, typically,

they establish prices at the level in effect on

the day before the incident occurs. Related to

this, the disaster planning team can research

local laws or regulations that protect against

price increases in periods of disaster. 

Ensure Interoperable 

Communications 

To continue providing essential services after

a disaster, essential staff members need 

systems and equipment that allow them to

communicate with one another, whether 

onsite, at home, or traveling, and to retrieve

and record data in client records and other 

files. They also need systems and equipment

that enable them to communicate with key

partners (e.g., frontline emergency responders;

staff at alternate facilities; nonessential staff; 

clients in residential settings, at their homes,

or at alternate facilities; clients’ families 

and other care providers; insurers and other

payers; vendors; the public). 

Examples of communications systems include: 

• At least one dedicated telephone line and

corded telephone on the premises for use

in case of power failure. Most cordless

telephones do not work without electricity,

and cell phone systems can jam from overuse;

also, individual cell or cordless phones will

need recharging. (Note: Corded phones

may run out of power after several hours if

they are linked by fiber-optic [as opposed to 

48 
49 

Chapter 4—Continuity Planning

 

copper] wires to the telephone company’s

central office.) 

• Cell phones with text messaging

capabilities, personal digital assistants, or

Internet-based telephone accounts. 

• Two-way radios (e.g., inexpensive walkietalkies), satellite phones (rented or

purchased), and other devices for personto-person communications when cell and

landline phones are inoperable. Some of

these communications devices may not be

secure, so providers must be careful when

relaying client information over them. 

• An Intranet hot site, which is a private,

password-protected area that can be

accessed only by authorized users and

which can be used to receive status 

information from, and provide information

to, employees in a disaster situation. 

• An offsite telephone number that employees

can call to report status and obtain

information. Programs can partner with

programs in other localities to provide one

another with emergency calling numbers. 

• Battery operated laptops with software

and memory capacity enabling access to

clinical data stored at an offsite server if 

the primary facility network is inoperable. 

• Computers at guest locations that are 

loaded with software capable of running

the program’s necessary files and

databases or that have the ability to

access the program’s hosted software site

containing this information. 

• Emergency contact information in multiple 

formats (e.g., stored in a computer

database; entered on paper copies stored

at the office, at home, and in vehicles; 

programmed into office phones for speedExhibit 4-5. Communication Tree 

The coordinator initiates distribution of a message by contacting the people on the branches directly 

below him or her. Those people then contact those below them on the branch. The final people to 

receive the message contact the coordinator, completing the chain and confirming that everyone has 

been informed. If callers cannot reach an assigned contact, they move to the next person down the 

branch, passing along the name or names of those who could not be reached. This information is 

passed along until it reaches the coordinator. 

Coordinator 

home phone, work 

phone, cell phone, 

email 

Staff 

home phone, work 

phone, cell phone, email 

Staff 

home phone, work 

phone, cell phone, email 

Staff 

home phone, work 

phone, cell phone, email 

Staff 

home phone, work 

phone, cell phone, email 

Staff 

home phone, work 

phone, cell phone, email 

Staff 

home phone, work 

phone, cell phone, email 

Staff 

home phone, work 

phone, cell phone, email 

Staff 

home phone, work 

phone, cell phone, email 

Staff 

home phone, work 

phone, cell phone, email 
Disaster Planning Handbook for Behavioral Health Treatment Programs

 

dialing; stored in cell phones). This would

include the contact information collected in 

Worksheet B3 (in Appendix B). 

• Memoranda of Understanding with

amateur radio (ham) operators for

assistance in emergency communications. 

• An agreement with local TV and radio

stations to communicate the program’s

status to the public in emergencies. 

• Routine reminders to staff members to 

print or back up to a second location their

computer-based personal calendars, address

books, and other critical databases, such as 

by synchronizing them to a handheld device

that can be password protected. 

• Multiple means of broadcasting alerts to

staff and clients (e.g., intercom for withinfacility communications; out-of-town phone

number that dispersed staff members can

call for information about program status;

group messaging via cell phone, email, or

Internet; closure listings via TV and radio;

instant messaging via social networks,

such as Twitter). 

• A communication tree, which is an 

arrangement that distributes responsibility

among staff to contact all personnel in case

of emergency (Exhibit 4-5). 

Exhibit 4-6 provides information on three

priority services that can help behavioral

health treatment programs communicate

in emergencies: Government Emergency

Telecommunications Service (GETS),

Wireless Priority Service (WPS), and Priority

Listing for Electric Service. The disaster

planning team can research whether its

program is eligible for these services. 

The behavioral health treatment program must

apply to be accepted into the GETS and WPS

systems. The program may be asked to obtain a

government sponsor and may have to submit a

letter explaining the nature of the relationship

between the sponsor and the program, the role

that the program plays in community disaster

response efforts, and the staff roles that will

need priority service and why. 

The disaster planning team can inventory its

current communications systems to ensure

that redundant, compatible systems have 

Exhibit 4-6. Priority Communications in an Emergency 

Service Description 

Government 

Emergency 

Telecommunications 

Service (GETS) 

Provides priority access to the switches that route telephone calls. This service is most 

useful during an event when telephone systems are not damaged but the circuits are 

overloaded. In this situation, the caller usually hears a very fast or very slow busy signal 

after the number is dialed, indicating that too many people are making calls at the 

same time. By using a GETS calling card, subscribers have priority access to the circuit, 

which allows the call to go through. GETS cards are free, but there is a small fee-perminute charge when they are used. Further information can be found at http://www. 

dhs.gov/government-emergency-telecommunications-service-gets. 

Wireless Priority 

Service (WPS) 

Provides priority access to the cellular towers that route cell phone calls. This service 

is most useful in situations when the cellular infrastructure is intact but the circuits are 

overloaded by a large number of callers. In this situation, the caller usually receives a 

message indicating that the call cannot be completed or receives a fast busy signal. WPS 

subscribers receive priority access through the cellular phone system. WPS is attached 

to a specific cell phone number, and the monthly fee is added to the phone bill. Further 

information can be found at https://www.dhs.gov/wireless-priority-service-wps. 

Priority Listing for 

Electric Service 

Ensures first priority for electric service restoration, following service disruption or 

shortage, to organizations that provide vital services or that would be most adversely 

affected by lack of service. In some areas, priority services may not be available to 

nonhospital healthcare providers. The disaster planning team should contact the 

local power company to learn about eligibility. 

50 
51 

Chapter 4—Continuity Planning

been created for person-to-person and data

communications and that the personnel

authorized to use those systems in a disaster

situation have access to authentication 

procedures and passwords. The team can

also seek advice and assistance from its 

local disaster planning body and the State

disaster behavioral health coordinator on 

obtaining the equipment, “gateway” devices

or patches that enable interoperability,

and permissions for communicating with

emergency responders in disaster. The 

team can use Worksheets B15 and B16 (in

Appendix B) to ensure that it has considered

a range of options for ensuring interoperable

communications. 

Protect Vital Records 

and Databases 

Treatment programs may consider housing

their IT equipment offsite at specialized

data centers, which offer customers a safe, 

secured environment with redundant systems

ensuring uninterrupted processes. Programs

also are encouraged to convert from paper

medical records to electronic health records 

(EHR; also known as electronic medical 

records, or EMR). These steps can circumvent

many of the records-related problems that

can occur in a disaster (Exhibits 4-7 and

4-8). For example, EHR stored at a secure

offsite server, such as one hosted by a medical

records software company, can be accessed

even if paper records are destroyed at the

original facility, and they can be readily

accessed by the program if it has relocated

to an alternate site. In addition, EHR can 

be transferred, efficiently and securely, to

another provider as needed. 

Information on EHR can be obtained from the 

Office of the National Coordinator for Health 

Information Technology, U.S. Department of 

Health and Human Services, at 

http://healthit.gov. 

Psychiatric programs that accept Medicare 

and Medicaid are eligible for incentives for 

adopting certified EHR technology. Programs 

that do not successfully demonstrate 

meaningful use of EHR technology by 2015 

will have a payment adjustment in their 

Medicare reimbursement. Information is 

available from the Centers for Medicare 

and Medicaid Services at https://www.cms. 

gov/Regulations-and-Guidance/Legislation/ 

EHRIncentivePrograms/index.html. 

To ensure all appropriate records remain

accessible or are transferred as needed in a 

disaster situation, the disaster planning team

can work with management to ensure there is

a current inventory of records and databases

(e.g., temporary and permanent records,

those stored in all formats and media). The

inventory also can include a list of current

software versions necessary to support

functions and files and contact information 

for the software and hardware companies. 

From this comprehensive inventory,

personnel assigned to this task can identify

the records, databases, and software 

necessary to perform essential functions

and to restore normal operations after a

disaster. Some fields in a database may not

be essential and can be sorted out if needed 

to save space on paper or on a hard drive. 

Worksheet B17 (in Appendix B) can be

used to ensure that plans are in place for

protecting all vital records and databases. 

The disaster planning team can check to

confirm whether computer systems staff has

in place a schedule for regularly updating

each vital record or database and backing up

each update on a remote server. The team

also should ensure that copies on paper,

CD-ROM, or encrypted external memory

drives can be kept at an alternate location or

in a portable, waterproof, and fireproof case

that can be carried to an alternate facility as

needed; this case is typically referred to as a 

facility go kit (distinct from the personal go

kit addressed in Chapter 3). 
Disaster Planning Handbook for Behavioral Health Treatment Programs

Exhibit 4-7. Benefits of Electronic Health Records (Example 1) 

St. John’s Regional Medical Center in Joplin, MO, converted from paper to EHR just weeks before a 

tornado devastated the town in May 2011, and this may have “saved lives,” according to Health and 

Human Services Secretary Kathleen Sebelius. Patient medical information was relayed within hours to 

outlying hospitals treating tornado victims, and St. John’s was able to operate effectively for weeks in 

a mobile medical unit. “Think of a typical hospital waiting room, and the infamous clipboard where 

somebody is being asked to put together their medical history and prescription regime by memory, and 

add a huge traumatic incident on top of that,” Secretary Sebelius said in an Associated Press interview. 

“There’s no question that . . . the availability of an electronic record may have actually saved lives. 

They were able to immediately go into the treatment phase and not spend a lot of energy trying to 

reconstruct (records).” 

Source: Zagier (2011). 

Exhibit 4-8. Benefits of Electronic Health Records (Example 2) 

Access Family Care (AFC) is another Missouri provider that averted a communications breakdown 

following the May 2011 tornado. The smaller of its two locations in Joplin, which provided primary 

care and behavioral health services, was completely destroyed. The organization had converted to 

EHR more than 2 years previously. Clinicians could access records from desktop computers or mobile 

devices, and they could reenter the system at the point where they left off without needing a repeat 

login. The system had many other useful features, such as e-prescribing and interconnection with a 

third-party lab. 

The core systems and applications were hosted and maintained by an IT company in an offsite 

building. The tornado destroyed that building—except for the data center itself, which was in a 

reinforced section that survived. The IT company relocated to temporary quarters and resumed 

operations within half a day. “This proved critical for the health center. When they reopened in the 

days immediately following the storm, AFC became the focal service delivery point for their own 

patients, as well as an emergency access point for others in the community, providing emergency 

medical triage and medication refills for community residents in need, while continuing to manage 

direct care and assist their own staff and staff families who were affected by the storm. . . . The 

experience of Access Family Care in Joplin, as well as of other community health centers at the 

epicenter of recent disasters, underscores the importance of investment in HIT [health information 

technology] at both the health center and community level. The operating costs incurred by the 

center are a manageable share of the overall budget and allow for operational and programmatic 

efficiencies while supporting the delivery of care. In the wake of the recent tornado, these dollars are 

clearly money well spent.” 

Source: Shin and Jacobs (2012, pp. 4–5). 

Any electronic forms that are essential for

continuity of operations and emergency

response (e.g., forms for reporting and

recording disaster response measures

such as daily situation reports; records

of expenditures and obligations; client

assessment, intake, treatment planning, and

discharge forms) should be available in paper

copies as backup when the power is down or

systems are inoperable; these can be kept

in the facility go kit. The facility go kit also 

might contain forms required for medications

ordering, administration, and management,

as well as client progress note forms and

other client forms (e.g., drug testing forms). 

Computer applications and data should be

prioritized by management staff responsible

for this function so that those most critical to 

operations are recovered and brought back

online first following a disaster. A plan should 

be developed for disassembling, transporting, 

52 
53 

Chapter 4—Continuity Planning

and reassembling any necessary equipment

in an evacuation. 

The behavioral health treatment program

must ensure that client confidentiality

is maintained as the program shares

information with other sites for client 

transfers and as it creates duplicate

records, such as for the facility go kit

(per requirements of 42 Code of Federal

Regulations [CFR] Part 2, Health Insurance

Portability and Accountability Act [HIPAA],

and Health Information Technology for

Economic and Clinical Health Act). 

Guidance provided by the Office for Civil

Rights, U.S. Department of Health and

Human Services, following Hurricane

Katrina is excerpted in Exhibit 4-9. (Updated

guidance may be issued in future disasters.)

If staff members find themselves in a 

situation in which confidentiality must be

broken, they should attempt to contact the

State agency that oversees treatment of

behavioral health disorders to explain the

situation. If that is impossible, they should

document the circumstances and report the

breach as soon as possible. 

Develop Resources To Manage 

Human Capital 

As discussed in the Mitigate Risk section of

Chapter 3, the disaster planning team can

take steps in advance to limit the extent

to which staff members are affected by

any disaster that occurs. The team also

can create, in advance of any event, a list

of providers of social services that will be

available to support staff members with

personal emergency needs (e.g., medical

assistance, crisis counseling, temporary

housing). 

An effective disaster plan provides a

mechanism for informing staff members

when the plan has been activated and how

each person should respond (i.e., as an

essential staff member who should report

immediately for duty or as a nonessential 

staff member who should wait for further 

instruction). To ensure effective deployment

of personnel, the disaster planning team

needs to have in place—and communicate

through training and other means—a clear

delineation of the staffing chain of command

and leaders’ authority in a time of disaster,

if it is different from the chain of authority

during regular operations. There also needs

to be a contact list of all staff members, 

including emergency contact information

and after-hours locations. (Personal contact

information, such as home and cell phone

numbers, should be shared on a need-toknow basis through the chain of command,

and the information should be used only for

appropriate purposes.) 

Multiple means of communicating among

staff need to be in place (see Ensure

Interoperable Communications, earlier in this 

chapter). Information on staff credentials and

levels of expertise will be useful, to ensure

that no one is moved into an assignment he

or she is not trained or prepared to perform. 

An individual’s willingness to work in a

disaster situation will be affected by concerns

about family, personal safety, and pet care

(Meredith, Eisenman et al., 2011). The

disaster planning team can recommend

policies that support staff members as they

serve during the disaster. These may include

policies that: 

• Provide staff members with advance 

training in disaster self-care. 

• Ensure access to phones or Internet to

check on family members while working

through a disaster situation. 

• Allow for adjustments to shift schedules,

as needed to perform essential

functions while also managing personal

responsibilities (maintaining 8-hour or

shorter work shifts if possible). 

• Provide for compensation to employees

who work additional hours in the disaster 

situation. 
Disaster Planning Handbook for Behavioral Health Treatment Programs

Exhibit 4-9. Office for Civil Rights HIPAA Guidance Following Hurricane Katrina 

September 2, 2005 

U.S. Department of Health and Human Services Office for Civil Rights
 

Hurricane Katrina Bulletin: HIPAA Privacy and Disclosures in Emergency Situations
 

Persons who are displaced and in need of health care as a result of a severe disaster—such as Hurricane 

Katrina—need ready access to health care and the means of contacting family and caregivers. We 

provide this bulletin to emphasize how the HIPAA Privacy Rule allows patient information to be shared 

to assist in disaster relief efforts and to assist patients in receiving the care they need. 

Providers and health plans covered by the HIPAA Privacy Rule can share patient information in the 

following ways: 

Treatment. Healthcare providers can share patient information as necessary to provide treatment. 

Treatment includes: 

• Sharing information with other providers (including hospitals and clinics). 

• Referring patients for treatment (including linking patients with available providers in areas where the 

patients have relocated). 

• Coordinating patient care with others (such as emergency relief workers or others who can help in 

finding patients appropriate health services). 

Providers can also share patient information to the extent necessary to seek payment for these 

healthcare services. 

Notification. Healthcare providers can share patient information as necessary to identify, locate, and notify 

family members, guardians, or anyone else responsible for the individual’s care of the individual’s location, 

general condition, or death. The healthcare provider should get at least oral permission from individuals, 

when possible; but, if the individual is incapacitated or not available, providers may share information for 

these purposes if, in their professional judgment, doing so is in the patient’s best interest. 

Thus, when necessary, the hospital may notify the police, the press, or the public at large to the extent 

necessary to help locate, identify, or otherwise notify family members and others as to the location and 

general condition of their loved ones. 

In addition, when a healthcare provider is sharing information with disaster relief organizations that, 

like the American Red Cross, are authorized by law or by their charters to assist in disaster relief efforts, 

it is unnecessary to obtain a patient’s permission to share the information if taking the time to get 

permission would interfere with the organization’s ability to respond to the emergency. 

Imminent danger. Providers can share patient information with anyone as necessary to prevent or 

lessen a serious or imminent threat to the health and safety of a person or the public—consistent with 

applicable law and the provider’s standards of ethical conduct. 

Facility directory. Healthcare facilities maintaining a directory of patients can tell people who call or ask 

about individuals whether the individual is at the facility, their location in the facility, and general condition. 

Of course, the HIPAA Privacy Rule does not apply to disclosures if they are not made by entities covered 

by the Privacy Rule. Thus, for instance, the HIPAA Privacy Rule does not restrict the American Red Cross 

from sharing patient information. 

Excerpted from Office for Civil Rights (2005). 

54 
55 

Chapter 4—Continuity Planning

The team, working with human resource

personnel, should review personnel policies to

ensure they support continuity of operations

in a disaster. A central issue is educating

and preparing staff members so that they are 

willing to report for and stay on duty during

an actual event (Exhibit 4-10). Worksheet 

B18 (in Appendix B) can be used as a tool for

considering personnel policies pertaining to a

disaster. 

Exhibit 4-10. Building Staff Willingness To Respond in Disaster 

One OTP reported that during a hurricane, staff members abandoned their posts over concerns that 

they would be unable to get home to protect themselves and their families. To avoid a recurrence of 

that situation, the program developed a detailed disaster plan that, among other things, clearly advised 

staff members of their roles in a disaster and enunciated policies for compensating staff if the program 

closed because of a disaster. As a result of these measures, the OTP was better staffed in subsequent 

hurricanes. 

Source: Podus et al. (no date). 

57 

Chapter 5—Management of Prescription 


Medications
 

In This Chapter 

• Give Careful Oversight

to Clients on Prescription

Medications 

• Help Clients Access

Prescription Medications 

• Provide for Continued 

Methadone Dosing 

• Prepare for Transfers of

Patients 

• Treat the Guest Patient on 

Methadone Maintenance 

Treatment 

• Handle an Influx of Patients 

With Opioid Dependence 

• Address the Needs of 

Displaced Patients on

Buprenorphine 

• Refer or Treat Pain Patients, 

as Appropriate 

• Manage Supplies of

Controlled Substances 

Worksheet (see Appendix B) 

• B19 Checklist for 

Management of Prescribed

Medications 

This chapter covers disaster planning to support

clients who take prescribed medications for the

treatment of behavioral health disorders or for other 

medical conditions. The chapter also covers issues

regarding management of onsite controlled substances

during a disaster. 

Give Careful Oversight to Clients on 

Prescription Medications 

Clients on prescription medications will need to be

monitored to determine if the unusual circumstances 

have interrupted or altered their medication regimen.

Depending on the patient and situation, the effects

of medication changes can include withdrawal and

symptom return. Innumerable kinds of adverse drug

reactions also can occur. The majority of them are

related to drug interactions, occurring when the amount

or action of a drug in the body is changed—usually

increased or decreased—by the presence of another drug

or multiple drugs. For example, adverse reactions can

occur from the unanticipated interactions of prescribed

medications, methadone, illicit drugs, over-the-counter

products, and other substances. In cases of patients on

elaborate drug regimens—such as multidrug therapies

for HIV/AIDS, hepatitis C, or severe mental illness—

consultation with specialists will be necessary to manage

any transitions resulting from the disaster situation. 

Programs can facilitate care in disaster conditions

for their own patients on prescribed medications by

proactively converting from paper medical records to

electronic health records. Electronic recordkeeping

avoids problems caused by destruction of paper records

in disaster and facilitates the transfer of those records to 

an alternate facility or guest provider (see Protect Vital

Records and Databases, in Chapter 4). 

Help Clients Access Prescription 

Medications 

Clients may be on prescribed medications for treatment

of mental disorders (e.g., antipsychotic medications, 
Disaster Planning Handbook for Behavioral Health Treatment Programs

benzodiazepines, selective serotonin reuptake

inhibitors, barbiturates). Clients also may

be on one or more prescribed medications

for treatment of substance use disorders 

(e.g., buprenorphine, naltrexone, disulfiram,

acamprosate). In addition, clients may take

prescribed medications for medical conditions

(e.g., hepatitis C, HIV/AIDS, diabetes, high

blood pressure, pain). 

In a disaster, clients may need to have their

prescriptions refilled due to losing access to

or running out of their medications. Clients

who are unable to take their regular doses

can experience one or more of the following

symptoms, depending on their diagnoses

and medications: sudden return of psychotic

symptoms (e.g., hallucinations, delusions),

recurrence of other psychiatric symptoms (e.g.,

depression, anxiety), withdrawal symptoms,

relapse to substance use, or deterioration of

physical condition. Some of these effects can

be directly or indirectly life threatening. In

addition, people who become emotionally or

mentally unstable or experience a relapse to

substance use because of lack of access to their 

medications may be at risk for unnecessary or

lengthy hospitalization or institutionalization,

especially if the cause and the treatment of

their condition are unknown by providers of 

emergency care. 

To lessen the likelihood of clients experiencing

medication-related problems, the disaster

planning team can recommend that the

program adopt policies to educate clients

on how to handle emergency situations. For

example, clients can be assisted in reviewing

their options for obtaining prescription

replacements and refills under various

scenarios, such as if the clinic or their 

primary pharmacy is not open or if they are

relocated without advance notice because of an 

unforeseen event. Clients also can be educated 

to include a 7-day supply of medication in their

household preparedness supplies (American

Red Cross, 2009). Clients can be advised to

carry all of their medications with them if they

are relocated, even temporarily, and to bring

with them the following items so that they can 

more easily obtain medication refills, as needed,

from a new medication-dispensing facility: 

• A photo ID 

• Medication containers of currently

prescribed medications (even if empty) 

• Written prescriptions 

• Packaging labels that contain dose,

physician, and refill information 

• Any payment receipts that contain

medication information 

The program’s executive director or other

designated representative can talk to the

local and State public health departments to

find out whether psychotropic or substance

abuse treatment medications are included in 

the public stockpile and to obtain clarification

on the disaster conditions under which such 

medications would be made available to the 

program’s clients. 

A 2006 review of the response to Hurricanes

Katrina and Rita found that locations 

receiving evacuees were not prepared to

support the prescription replacement/refill

needs of arriving individuals. The report

noted, “For some people with psychiatric

disabilities, this remains one of their chief 

concerns for the next hurricane season” 

(National Council on Disability, 2006,

Section III, B2). Therefore, the topic of

medication maintenance for clients should 

be addressed with local disaster planning

committees, especially with the operators

of shelters and evacuation receiving sites.

Continued client access to prescription

medications can be a topic included in

tabletop or functional exercises that test the

disaster plans of the program, community,

and State (see Chapter 7). 

Provide for Continued Methadone 

Dosing 

Methadone is a Schedule II substance 

under the Controlled Substances Act, which 

means that prescribing, dispensing, and 

58 
Chapter 5—Management of Prescription Medications

59 

transporting methadone is tightly regulated

by the Drug Enforcement Administration

(DEA), under 42 Code of Federal Regulations

(CFR) 8.12. Many patients on methadone

maintenance treatment (MMT) for opioid

dependence receive their daily dose at their

opioid treatment program (OTP). For such

patients, a disaster that cuts them off from

the OTP and their daily dose of methadone

can precipitate withdrawal symptoms and

increase risk of relapse. 

To ensure continued dosing in all

circumstances, an OTP will need access to 

patients’ dosing information or will need to

be able to provide that information to another

program that will provide guest dosing. This

will be difficult if computer-based records

are inaccessible or lost in a disaster. As a 

mitigation step, the OTP should store and

regularly update patient medical records

(including dose levels and take-home

privileges) at a secure location (e.g., an offsite

server located in a reinforced building). The

program also should be ready to quickly and

securely transfer patient records and the

supporting software to an alternate location

(see Protect Vital Records and Databases, in

Chapter 4). 

Some OTPs provide patients with smart 

ID cards. Each card contains the patient’s

photograph and encrypted medical

information. A program that uses such

cards should ensure that other OTPs to 

which patients may be transferred have the

equipment (and the electric or battery power)

to read the cards. The program also should

provide a backup method for transferring

medical records and verifying patient status

and identity, because patients affected by

disaster may lose all possessions, including

their ID cards. Many patients on MMT who

were affected by Hurricanes Katrina and

Rita experienced this loss (Maxwell, Podus, &

Walsh, 2009). 

Some State Opioid Treatment Authorities

(SOTAs) maintain a central database with

identifying information on patients on MMT,

including dosage levels, admission dates, and 

take-home privileges. The disaster planning

team should check with its State agency that

oversees behavioral health services to learn 

the procedures for accessing patient records

in emergencies. Issues to cover include: 

•	 The process for accessing the OTP’s own

patient information when records at the

program are destroyed or inaccessible. 

• The process by which a receiving OTP will be

able to access the records of guest patients. 

• Whether an OTP can rely on guest patients

for dosage information when the home

OTPs are not able or available to verify the

information. 

• Whether the OTP will have to obtain 

patient releases for that information. 

Some States have developed statewide

healthcare communications systems through

which dosing information can be securely

transferred. Details on one such system, the

Washington System for Tracking Resources,

Alerts, and Communication, are included in 

Appendix E. An example of the challenges in

patient dosing after a disaster is illustrated

in Exhibit 5-1. 

Information on the State of Washington’s 

statewide healthcare communications 

system, through which dosing 

information can be securely transferred, 

is available at http://www.doh.wa.gov/ 

PublicHealthandHealthcareProviders/ 

EmergencyPreparedness/WATrac.aspx. 

In some emergency situations (e.g., an

impending snowstorm or hurricane that is

expected to make street travel difficult for

a few days), the optimal choice may be to

provide patients with extra take-home doses.

OTPs can prepare in advance to submit

emergency programwide exception requests

to the Substance Abuse and Mental Health 

Services Administration (SAMHSA) and to

the SOTA, where applicable, to extend takehome privileges, or to dispense extra takehome doses for a reasonable period of time. 
Disaster Planning Handbook for Behavioral Health Treatment Programs

Exhibit 5-1. Distant Dispersal of OTP Patients 

An OTP administrator reported that his clinic prepared for disaster situations by backing up its data 

to an offsite location. This database could be directly accessed by other clinics owned by the same 

company. In addition, the administrator retained hard copies of patient names and dosing histories. This 

preparation proved insufficient, however, to deal with the impact of a major hurricane. In its aftermath, 

the administrator had to spend hours on the phone with staff members at alternate facilities throughout 

the United States and not owned by the same company, verifying data and dosing information for 

patients who had been relocated. “Planning is great and having channels and [cooperative agreements] 

with other programs is great,” he said, “but you have to understand that people are going to end up 

almost anywhere.” The administrator was particularly frustrated by the reluctance of some alternate 

facilities to accept his verification. Instead, they requested a signed faxed document authorizing the 

patient transfer. Power outages made complying with this request extremely difficult. 

Source: Podus et al. (no date). 

Exception requests may be submitted to

SAMHSA online, by fax, or by mail. According

to SAMHSA, OTPs that submit requests online

will typically have a decision, also viewable

online, within 1 hour of the submission. 

Information on making requests for exceptions 

to the Federal opioid treatment standards 

is available at http://www.dpt.samhsa.gov/ 

regulations/exrequests.aspx. 

A SOTA directory is available at http://dpt2. 

samhsa.gov/regulations/smalist.aspx. 

Prepare for Transfers of Patients 

In an impending disaster, a behavioral health

treatment program may have little time in

which to activate its plan for continuity of

operations (see Chapter 4). This factor is

particularly crucial for a residential program

that provides medical detoxification or for an

OTP, both of which must rapidly accomplish

several extra steps in its continuity plan. 

A program that provides onsite medical

detoxification must prepare for evacuation,

which will involve the transfer and tracking

of patients and their medical information

to an alternate location—or to another 

program with which it has a Memorandum

of Agreement (MOA). Similarly, an OTP 

must prepare for transfer and tracking of

patients receiving methadone to an alternate

location or to another clinic that will be able 

to provide guest dosing. Steps to accomplish

these transfers should be included in the 

program’s continuity plan. 

Exhibit 5-2 provides an example of an OTP’s

continuity plan that was executed before

landfall of Hurricane Hugo. 

Treat the Guest Patient on 

Methadone Maintenance Treatment 

Every OTP should have procedures for how

to handle people who arrive with or without

advance arrangement and who request

courtesy methadone dosing after a disaster.

The disaster planning team needs to consider

how many such patients its facility can

handle. A small program that does not have

the resources to treat guest patients should

consider developing plans and procedures for

referring prospective guests elsewhere. This

can be formally accomplished through an

MOA with a larger provider (see Negotiate

Memoranda of Agreement, in Chapter 3). 

Programs that have the capacity to treat

guest patients should follow guidance

provided by SAMHSA to State Methadone

Authorities (SMAs) in States directly affected

by Hurricane Katrina and included in the 

60 
Chapter 5—Management of Prescription Medications

 

 

 

 

 

 

Exhibit 5-2. An OTP’s Continuity Plan Executed Before Hurricane Hugo 

In 1989, Hurricane Hugo hit South Carolina. The Opioid Treatment Center of Charleston was located 

in a flood zone and near a major river. The staff thought the building would flood and that the streets 

leading to the program would be impassable for days. Staff members had 5 hours to notify 400-plus 

patients that the program might be unable to operate for a few days, to contact State and Federal 

officials to obtain permission to dispense extra take-home doses, to dispense the medication, and to 

get home themselves to secure their homes or relocate. 

The program had agreements with OTPs in other parts of the State, in neighboring States, and with 

hospitals and mental health centers (for patients with co-occurring disorders). The six counselors, two 

nurses, an administrative assistant, and a program director did the following: 

1. Contacted the medical director to report back to the facility to sign take-home orders and to sign 

emergency take-home requests to be sent to State and Federal authorities. 

2. Called each patient to inform him or her of the situation, using agreed-on emergency contacts where 

necessary, and to tell the patient to come to the clinic to pick up the extra doses. 

3. Communicated with OTPs in neighboring counties that might serve patients should the program be 

unable to reopen within 3 days. 

4. Contacted a local mental health service provider to determine whether all patients served by them 

had enough prescriptions to ride out the storm and aftereffects. 

5. Informed nearby emergency departments (EDs) of the OTP’s closing, in case patients went to an ED 

for methadone because they did not receive extra take-home doses. 

6. Called the local public communications systems to ask that they broadcast the program’s closure. 

All these procedures had been established with scripts that each staff member had access to and used 

during the disaster. 

There was only one incident: a pregnant mother could not get in to pick up her extra doses. She was 

assisted by local ED staff members, who communicated with the medical director for guidance and 

assistance. Agreements remain in place with medical and mental health centers, OTPs, and other 

community support agencies. 

Source: Shirley Beckett Mikell, Clinical Supervisor, The Opioid Treatment Center of Charleston, SC, personal communication, 

January 11, 2010. 

Federal Guidelines for Opioid Treatment Address the Needs of Displaced (SAMHSA, 2013). See Exhibit 5-3. Patients on Buprenorphine 

Handle an Influx of Patients With 

Opioid Dependence 

A disaster may disrupt distribution of street

drugs, causing individuals dependent on illicit

opioids and not in treatment to turn to an OTP

for help. A disaster also can be a life-changing

experience that impels people to enter

treatment. OTPs should anticipate a potential

rush of new patients. Guidance provided by

the Division of Pharmacologic Therapies (DPT)

on handling displaced patients who are opioid

dependent and not currently in treatment is

presented in Exhibit 5-4. 

There are hundreds of thousands of patients

receiving buprenorphine products for the

maintenance or detoxification treatment of 

opioid dependence. Most of these patients are

being treated by office-based, Drug Addiction

Treatment Act-waived physicians, in settings

other than OTPs. Buprenorphine patients

displaced by disasters may be treated in OTP

settings. 

Additional buprenorphine treatment resources 

may be found at the Buprenorphine Physician 

& Treatment Program Locator at http:// 

buprenorphine.samhsa.gov/bwns_locator. 

61 
Disaster Planning Handbook for Behavioral Health Treatment Programs

Exhibit 5-3. Guidance for Treating OTP Patients From Areas Affected by Emergency Closure of 


Programs in the Event of a Disaster
 

Programs receiving displaced patients should make every effort to contact the home treatment 

program of people who have had to evacuate the area in which they live after an emergency or 

disaster. Information about the program may be obtained from the OTP Directory on the DPT Web 

site (http://dpt.samhsa.gov) or at the SAMHSA Behavioral Health Treatment Services Locator at http:// 

findtreatment.samhsa.gov. In an emergency, program personnel may disclose information to the 

program medical director; program physician or mid-level practitioner, as appropriate; registered nurse; 

or dosing nurse without a patient’s signed consent. If unable to contact the patient’s home program, 

the OTP receiving a displaced patient should follow the procedures listed below along with existing 

emergency plans: 

• The emergency guest patient should show a valid form of picture identification that includes an 

address in close proximity to the area affected. 

• The patient should show some type of proof that indicates the patient was receiving services from 

a clinic located in one of the affected areas. Examples of proof may include a medication bottle, 

program identification card, or a receipt for payment of fees, etc. In cases in which the patient does 

not have any items of proof, including picture identification, the physician or mid-level practitioner, 

as appropriate, should use his or her best medical judgment combined with a stat drug test for the 

presence of methadone (lab test with quick turnaround, dipstick, or similar procedure). 

• OTP staff may administer the amount of medication that the patient reports as his or her current 

dose; however, each patient is reminded that the dose that is reported will be verified with the home 

program as soon as possible. It may be prudent to closely observe an unknown patient for several 

hours post-administration to ensure that the dosage decision was correct, or take appropriate medical 

action in the event the dose was too high. In cases in which the reported dose appears questionable, 

it is best to use good medical judgment when determining the dose level. In certain cases in which 

the patient can demonstrate no prior enrollment in treatment or medication dosage amount, it may 

be advisable to treat the patient as a new admission and follow initial dosing procedures for a routine 

admission. (See 42 CFR § 8.12 (h) (3) (ii).) 

• Emergency guest patients should be medicated daily with take-home doses provided only for 

days that the program is closed (Sundays and holidays). The clinic should have a plan to administer 

methadone appropriately and safely on days or at times when the program is closed. If the patient’s 

current take-home status is verified, take-home doses may be provided in accordance with State and 

Federal regulations (42 CFR Part 8). In the case of a patient who is unable to receive daily treatment 

at the program location due to medical hardship, travel restrictions, or other hardship, take-home 

medication for unsupervised use may be considered using the SMA-168 “Request-for-Exception” 

process. 

• Documentation of services provided to displaced patients should be a priority for OTPs. The OTP 

should assign a clinic identification number and maintain a temporary medical record for each guest 

patient. Reasonable efforts should be made to contact the patient’s home program periodically 

to verify patient information prior to dispensing medication. The results should be recorded in the 

temporary chart. OTP staff should record the day, date, amount of medication administered to each 

patient along with any observations made by the staff. As time passes and affected OTPs reopen, 

some patients may elect to remain in treatment at the receiving facility and change from guest to 

permanent status. At the conclusion of emergency treatment, the receiving program may be asked to 

report to the SMA and/or SAMHSA the number of patients treated and the types of services provided. 

Excerpted and adapted from SAMHSA (2013, pp. 60–61). 

62 
Chapter 5—Management of Prescription Medications

63 

Refer or Treat Pain Patients, 

as Appropriate 

During a disaster, some people on opioid

medication for pain may lose access to

medication and experience withdrawal. Some

may seek help from an OTP. SAMHSA (2013)

recommends that such people be referred

to a local physician, preferably a pain

management specialist. See Exhibit 5-5. 

Manage Supplies of Controlled 

Substances 

OTPs should take steps to ensure an

adequate supply of approved opioid

treatment medications, such as methadone 

and buprenorphine, are on hand for

emergency dosing and other purposes (see

Chapter 6 on pandemic flu preparations).

Some emergencies may necessitate that a

behavioral health treatment program remove

controlled substances such as methadone 

Exhibit 5-4. Guidance on Working With Patients Who Are Dependent on Opioids and Not 

Currently in Treatment 

Individuals dependent on opioids—including heroin or prescription drugs—may arrive at the guest 

treatment program seeking help as a result of the disruption in the supply of street drugs. OTPs 

may admit, treat, and dose these patients under existing guidelines and regulations. Initiation on 

buprenorphine products may be appropriate for patients new to medication-assisted treatment. 

Excerpted from SAMHSA (2013, p. 61). 

Exhibit 5-5. Guidance on Working With Displaced Patients Treated by Pain Clinics 

Patients who are being treated for pain with methadone by a physician may contact an OTP when they 

run out of medication and have no access to the former treatment setting. The first response should 

be to refer the patient to a local physician, particularly a pain management specialist. Additionally, the 

SAMHSA guidelines provide the following guidance: 

• Patients, in general, are not admitted to OTPs to receive opioids only for pain, but there are 

exceptions to this principle. The Narcotic Addiction Treatment Act and the Drug Addiction Treatment 

Act (DATA) were established to allow for maintenance and detoxification treatment, using certain 

opioid controlled substances like methadone and buprenorphine. These requirements and limitations 

in no way affect the ability of a practitioner to utilize opioids for the treatment of pain when acting 

in the usual course of medical practice. Consequently, when it is necessary to discontinue a patient’s 

opioid therapy for the treatment of pain by tapering or weaning doses, there are no restrictions, under 

Federal opioid treatment regulations, with respect to the drugs that may be used. Because this is not 

considered “detoxification” as it is applied to addiction treatment, no separate DEA registration as an 

OTP or DATA waiver requirements apply. 

• Patients with a chronic pain disorder and physical dependence are managed by multidisciplinary 

teams that include pain and addiction medicine specialists. The site of such treatment may be in a 

medical clinic or in an OTP, depending on each patient’s need and the best utilization of available 

resources. Similarly, addiction patients maintained on methadone or buprenorphine are not 

prohibited from receiving needed pain treatment including, when appropriate, adequate doses of 

opioid analgesics. 

• Patients who are diagnosed with physical dependence and a pain disorder are not prohibited from 

receiving methadone or buprenorphine therapy in an OTP for either maintenance or withdrawal, if 

such a setting provides expertise or is the only source of treatment. 

Excerpted from SAMHSA (2013, pp. 61–62). 
Disaster Planning Handbook for Behavioral Health Treatment Programs

from the premises during evacuation or

relocation. The program needs to know, in

advance, legal procedures for moving the

controlled substances and the procedures

for requesting moves. DEA or the SOTA

can provide the most current advice on this 

matter. 

Emergency authorization for requests to move 

controlled substances in response to a disaster 

may be submitted to DEA via http://www. 

deadiversion.usdoj.gov/disaster_relief.htm. 

To facilitate the request process, the disaster

planning team can educate the DEA agent

for its jurisdiction, in advance, about the

controlled substances that it stocks and about 

the potential need for expedited permissions

in emergencies. The relationship between the

behavioral health treatment program and

the DEA agent can be fostered through joint

participation in the community’s disaster

preparedness planning and related practices

or drills. 

Programs should inform the local law

enforcement agency, in advance of any

emergency, that controlled substances are

on the property. The disaster planning team

may request that the facility be considered

for high-priority protection if looting is a 

concern or for police escort when transporting

program supplies to a new location. Again,

the program can facilitate these requests

by establishing relationships with the law

enforcement agency before any disaster

and ensuring that the appropriate law

enforcement contact information is available 

in the disaster plan. 

A program’s supply of controlled substances

may become inaccessible (e.g., if the

methadone safe is buried in rubble or under 

water). A representative of the program

should consult with the local DEA agent,

the SOTA, and the program’s medication

suppliers to develop contingency plans for

resupply. The local health department may

be able to facilitate resupplies from local

strategic stockpiles, hospital supplies, or

other sources. The treatment program can

coordinate, in advance, with these other 

parties to create signed agreements that

detail procedures and protocols for emergency

transfers of controlled substances. At a 

minimum, these agreements should be

reviewed and updated annually. 

Worksheet B19 (in Appendix B) is a

checklist of planning issues to support

patients who take prescribed medications

and to manage controlled substances in a

disaster. 

64 
65 

Chapter 6—Planning Issues for Pandemic 


Influenza
 

In This Chapter 

• Potential Effects of Pandemic 

Influenza 

• Procedures To Reduce 

Influenza Transmission 

• Vaccines 

• Antiviral Medications 

• Hygiene Policies 

• Staffing Policies 

• Staff Attitudes 

• Planning Assumptions for

Pandemic Influenza 

• Drafting and Activating the

Pandemic Plan 

Medical Offices and Clinics 

Pandemic Influenza Planning 

Checklist, from the U.S. 

Department of Health and

Human Services (HHS) and the

Centers for Disease Control and 

Prevention (CDC) can be used

in conjunction with this chapter.

It is available at http://www.

flu.gov/planning-preparedness/

hospital/medofficesclinics.pdf. 

A regional or global disease outbreak, known as a 

pandemic, presents a unique kind of hazard. Unlike

tornadoes, earthquakes, and other events typically

associated with the word disaster, the primary effects

of a pandemic would not be destruction of property and

traumatic injury, but rather sickness and death. 

Influenza is the infectious disease most likely to

become a pandemic. Influenza can spread throughout

the world in a matter of weeks and before sufficient 

quantities of antiviral medications and vaccines can

be produced and distributed. The Occupational Safety

and Health Administration (2009) estimates that

workplace absences could reach 40 percent during

peak weeks of a community outbreak. 

An influenza pandemic will likely recur in waves that

may last for months. A community that has been

affected by a pandemic may only partially recover

before experiencing another wave of illness. Because a

pandemic affects an entire region simultaneously, the

response and recovery help that might otherwise be

available could be very limited. 

A pandemic presents such a unique disaster scenario

that behavioral health treatment programs are

advised to develop a specific plan for pandemic

response. The disaster planning team can develop

this plan, or it can delegate the task to a pandemic

planning committee. The pandemic plan can be

attached to the basic plan as a Pandemic Appendix.

This chapter presents the information that should be

considered as this appendix is prepared. 

Potential Effects of Pandemic Influenza 

When influenza reaches pandemic proportions, the

operations of a behavioral health treatment program

can be adversely affected in multiple ways. Significant

numbers of staff members, clients, and residential 

patients may become ill or die. Staff shortages may occur

because workers have been quarantined, want to avoid

exposure, or must care for ill family members. There may

be increased mental stress on staff and clients. 
Disaster Planning Handbook for Behavioral Health Treatment Programs

66 

Specific client populations may be at special

risk of illness or complications. Typically, this

includes women who are pregnant (Exhibit

6-1) and people from racial and ethnic

minority groups (Exhibit 6-2). Other groups

that may be at special risk include people

who are 65 years or older; have asthma or

other chronic pulmonary, cardiovascular,

hepatic, hematological, neurologic,

neuromuscular, or metabolic disorders such 

as diabetes; are immunosuppressed; or are

residents of a nursing home or other chroniccare facility. Children younger than 5 and

children and youth on long-term aspirin

therapy also are at special risk (HHS,

2009a).*

 Exhibit 6-3 lists potential effects of

an influenza pandemic on the specific types of 

treatment programs. 

Procedures To Reduce Influenza 

Transmission 

CDC continuously updates its advice regarding

procedures to reduce influenza transmission.

These include annual vaccination for employees

(and vaccination against specific strains of

pandemic influenza as they are made available)

and minimizing potential exposure by

promoting good respiratory hygiene and cough

etiquette, separating symptomatic clients from

other persons, and a range of other actions. 

Seasonal influenza guidance for the general 

public and health professionals from CDC is 

available at http://www.cdc.gov/flu and from 

HHS at http://flu.gov. 

Exhibit 6-1. Pregnant Women at Special Risk From Influenza 

Pregnant women who contract influenza are at increased risk for severe illness or death, and babies born 

to them have increased risk of adverse outcomes (Rasmussen, Jamieson, & Breese, 2008). The disaster 

planning team should consider actions the program can take to mitigate risk for pregnant clients during 

a pandemic outbreak, such as the following: 

• Provide services to pregnant women in ways that minimize their exposure to others (e.g., in individual 

rather than group settings, in separate areas of the facility). 

• Educate women to protect themselves against infection while performing their roles as family 

caregivers and members of the workforce. 

• Help women develop a plan to maintain prenatal care while minimizing exposure. 

• Provide counseling to women on the benefits and risks—for themselves and for their fetuses—of 

influenza vaccine, antiviral medication, antifever medication, and antibiotics, such as for secondary 

bacterial pneumonia. 

• Support pregnant women in their compliance with physician recommendations for use of antiviral and 

other prescribed medications. 

Exhibit 6-2. Racial and Ethnic Minorities Disproportionately Affected by Influenza 

Historically, people from racial and ethnic minority groups have been disproportionately affected by severe 

influenza due to higher rates of underlying health conditions as well as cultural, educational, and linguistic 

barriers that interfere with adoption of intervention strategies (Hutchins, Fiscella, Levine, Ompad, & 

McDonald, 2009). To minimize disparities, programs can involve members of racial and ethnic minorities in 

its pandemic preparedness and response planning and facilitate their participation in community pandemic 

planning. Programs also can advocate for equitable allocation of resources including antiviral medications 

and vaccines. When providing pandemic planning education and services, programs can offer culturally and 

linguistically sensitive educational materials and interpreters for non-English-speaking clients. 

*

An influenza virus may affect people atypically. For example, in the 1918 pandemic, healthy young adults comprised

the predominant risk group. It is theorized that the virus triggered an overload of response from the immune system 

and that people with stronger immune systems were more susceptible to an overreaction to the virus. 
Chapter 6—Planning Issues for Pandemic Influenza

Exhibit 6-3. Potential Effects of Influenza Pandemic on Behavioral Health Treatment Programs 

Program Type Potential Pandemic Effects 

Outpatient 

Treatment 

Programs 

Client drop-in and attendance at individual appointments and group events may 

decline. Alternatively, client drop-in and attendance may surge because of concern, 

panic, or lack of other psychological or medical support. 

Clients may not heed instructions to stay home if experiencing influenza-like symptoms, 

and consequently transmit the illness to other clients and staff. 

Mental health emergencies may increase as the result of a disruption in client support 

and access to ongoing treatment. 

Services may have to be provided using procedures to reduce influenza transmission 

(addressed in the section below). 

Staffing shortages may occur as clinicians become ill or stay at home to care for ill family 

members. 

The entire program or specific services may close during local outbreaks of disease. 

Revenues may decline dramatically, with effects on the viability of the program. 

Residential 

Treatment 

Programs 

Patients may become ill and need to be isolated. 

Staff may need to take care of patients who become ill. 

The facility may be quarantined. 

Visitation may need to be suspended or highly restricted. Electronic communications 

may replace actual onsite visitation. 

Medically 

Managed 

Detoxification 

Programs 

Beds may be redirected for use by patients with influenza. 

Medical and nursing staff may be redirected to care for patients with influenza. 

Necessary antiviral drugs may be slow in arriving or not be available at the necessary 

levels. 

Influenza symptoms (e.g., fever, nausea, diarrhea) may be difficult to differentiate from 

withdrawal symptoms. 

A surge in patients may occur that includes people who are infected with influenza, 

people who misinterpret influenza symptoms as withdrawal symptoms, and people who 

seek psychological or medical support. 

Opioid 

Treatment 

Programs (OTPs) 

An OTP may need to provide patients with take-home methadone doses for longer 

periods than usual (following guidelines from the Substance Abuse and Mental Health 

Services Administration, Center for Substance Abuse Treatment [CSAT], Division of 

Pharmacologic Therapies [DPT]). 

The program may need to provide patients with take-home doses earlier in their 

recovery than usual (again, following CSAT’s guidelines). 

Increased numbers of patients may need to have doses brought to them because they 

have contracted a communicable disease. 

Hospital emergency departments may be operating at capacity and unavailable for 

methadone maintenance treatment of patients whose home OTP has closed. 

Patients in fear of not receiving scheduled doses may overwhelm the program as they 

seek additional take-home supplies or support. 

Programs may be at increased risk of theft or diversion of medications. 

Prevention 

Programs 

The program may be discontinued until the local pandemic crisis is over. 

67 
Disaster Planning Handbook for Behavioral Health Treatment Programs

68 

Some modified procedures require advance

planning and investment. For example,

increased staff telecommuting may require

improvements to the program’s communications

infrastructure and the development of policies.

Telephone or Web-based counseling may

require setup of equipment and testing that

ideally are conducted in advance of a pandemic.

Prior approval from funding sources, such

as insurance providers and Medicaid, for

substitute forms of counseling may be needed

to facilitate reimbursements. Any plans to

provide counseling through remote means

(e.g., telephone or Internet) need to specify how

clients who do not have telephones or computers

will access the service. In addition, the program

should review any program modifications (e.g.,

telephone or Internet counseling) for their

potential impact on patient confidentiality.

Programs can seek guidance on planning for

modifications to procedures during an influenza

pandemic from the State disaster behavioral

health coordinator. The program is also advised

to work with its attorney to ensure that

procedures comply with privacy requirements

and to develop documents for new procedures

(e.g., client release forms for phone, texting, or

Internet counseling. 

Procedures should be tested and practiced to

identify weaknesses in the plan and to prepare

staff. Chapter 7 provides information on

testing the plan and training staff to use it. 

Vaccines 

The disaster planning team can ensure that

the program has policies in place to facilitate

vaccination of staff and clients for seasonal 

flu, if medically indicated. The program’s

executive director or other appointed

representative can contact local and State

public health departments to learn about

the community’s policies on distribution for

a particular pandemic influenza vaccine,

when it becomes available, and to ask for the 

inclusion of the program’s essential staff, as

healthcare professionals, on the priority list. 

A decision on whether to provide residential

patients with the pandemic vaccine,

if available, should be made by senior

management in consultation with the local

health department. If vaccines are offered,

the program will need to implement policies

and consent forms to support this practice.

If possible, a patient’s pertinent medical

information (e.g., previous vaccinations and

responses, allergies, risks, contraindications)

should be reviewed before vaccinating. The

program may prefer to refer nonresidential

clients and staff to their primary care

providers or local clinics for vaccinations. 

Antiviral Medications 

The use of prescription antiviral medications

is an important strategy for suppressing the

spread of pandemic influenza (Homeland

Security Council, 2005). Recommendations

for antiviral drug use in an influenza

pandemic and plans for distribution of

public stockpiles of antiviral medications

continuously evolve. Priority distribution

of antivirals will be to workers at critical 

infrastructure organizations—those providing

goods or services essential to community

health, safety, or well-being. 

The program’s executive director or appointed

representative is advised to talk to contacts

at the public health department to clarify

whether antivirals from the public stockpile

will be made available to the program or

whether the program should purchase its own

supply. The team also should become informed

of the medical, legal, and ethical issues

involved in the use and rationing of antivirals. 

Purchase of an antiviral stockpile should

be considered by all programs, especially if

the program has a residential component,

serves clients who have compromised

immune systems, or serves women and

girls (as indicated in Exhibit 6-1, pregnancy

has been found to increase risk for severe 

illness or death from some influenza strains).

Antiviral stockpiling could be costly, but

financial assistance may be available from 
Chapter 6—Planning Issues for Pandemic Influenza

69 

manufacturers. All plans to stockpile should

be coordinated with local and State emergency

pandemic preparedness efforts and in

conjunction with other measures to protect

workers and maintain continuity of operations. 

A behavioral health treatment program with

medical staff may become an authorized point of

distribution (POD) for antiviral medications and

vaccines. The local or State health department

coordinating these efforts can provide guidance

on the requirements for becoming a POD. If the

program does not choose to become a POD, it

should establish plans to transport residential

patients to a location where vaccinations

are offered or to contract with the health 

department for personnel to come onsite to

provide vaccinations. 

Hygiene Policies 

In consultation with program management,

the disaster planning team can review and

revise hygiene policies, including policies to: 

• Encourage hand hygiene among staff and

clients. 

• Reduce spread of virus through respiratory

means (e.g., coughing etiquette). 

• Stock sanitation supplies (e.g.,

disinfectants, hand sanitizers, facial 

tissues, face masks). 

• Provide preventive education for staff

and clients (e.g., on the importance of

maintaining overall good health, avoiding

unnecessary exposure to people who are ill,

and keeping all suggested immunizations

up to date to protect against illness that

weakens the ability to fend off influenza). 

•	 Educate staff and clientele on influenza 

symptoms, social distancing procedures

(the public health practice of encouraging

people to keep their physical distance from

each other to avoid infection), and other

influenza-related topics. 

• Make alterations to sick leave policies

during pandemics to encourage those who

are infected or recently exposed to the

virus to remain away from the facility for

the duration of their contagious period. 

•	 Make temporary modifications during

pandemic conditions to the program’s

appointment policy to ensure that clients

who are contagious are not penalized for

canceling appointments at short notice. 

Exhibit 6-4 describes how a residential 

facility educated residents about flu

prevention hygiene and pandemic scenarios. 

Exhibit 6-4. Pandemic Education Provided to Staff and Residential Patients 

In our facility, monthly meetings are held for staff and residents that cover a range of topics focused 

on the importance of staying well. Some of these topics include correct hand washing techniques; 

proper use and disposal of tissues; and the importance of keeping warm, drinking enough fluids, and 

dressing appropriately. We also talk about how we would manage an outbreak, including containment 

of [residential] houses, and staff management of infectious diseases (e.g., staff stress, communications, 

shifts). Staff and residents need to know whom they can contact for further information. 

“Talking about it” includes more than just specific education sessions. In our cases, it means building 

and maintaining an environment in which individuals feel they are able to tell someone if they are not 

feeling well and in which monitoring signs of illness is viewed as a positive response rather than an 

intrusion. Effective communication will also enable us to identify the early signs of stress and anxiety 

among our residents for early intervention. 

Excerpted from Hughes (2010, pp. 39–40). 

Staffing Policies 

The order of succession in the disaster plan

may need to be extended several people deep

to ensure that leadership and other essential 
Disaster Planning Handbook for Behavioral Health Treatment Programs

70 

positions are filled. In addition, multiple

layers of staff trained in sanitation duties (e.g.,

disinfecting surfaces, changing linens, removal

of trash) may need to be identified because

sanitation will be essential during a pandemic. 

The program’s pandemic plan can provide

direction for rapid identification of staff

members who become symptomatic and for

staff substitutions so those identified workers 

can be sent home. If staff levels become 

critically low, the program may need to hire

qualified staff members from a staffing agency,

or it may need to refer or transfer clients.

However, if there is concern about contagion,

other programs may not be willing to treat

guest clients even if a mutual aid agreement

had been negotiated. Local hospitals also

may be overwhelmed with ill patients and

find it difficult to dispense methadone to

referred OTP patients or to treat patients

needing medical detoxification. The disaster

planning team is advised to consider these

scenarios. The executive director or appointed

representative should clarify assumptions

with the behavioral health treatment 

programs with which the program has mutual

aid agreements, with staffing agencies, and

with hospital representatives. 

The disaster planning team should identify

alternative ways to serve clients if the

program reduces its operations or closes, and if

other programs are not immediately available

to serve its clients. For example, an OTP may

provide patients who qualify with take-home

doses for an extended duration, following

CSAT’s DPT guidance for pandemic situations. 

Staff Attitudes 

A survey of 1,835 public health workers

indicates that the most important factor

influencing workers’ willingness to respond

for duty during a pandemic is their confidence 

that they can perform the emergency

duties expected of them and that their 

response makes a difference. A second factor

influencing workers’ willingness to respond

is their perception of whether the pandemic 

threat is significant. Workers who felt they

could be effective and that the threat was 

high had a declared rate of willingness to

respond that was 31.7 times higher than the

rate for workers who perceived that both

their ability to respond and the disaster

threat were low (Barnett et al., 2009). 

The implication for behavioral health

treatment program disaster planners is that

staff competencies and attitudes need to be

assessed to ensure that all employees are

prepared, and feel prepared, for the duties

they will be expected to perform under

pandemic conditions. Workers who are not

confident of their abilities may need more

training in their designated disaster roles

and education about how their contributions 

make a difference. Barnett et al. (2009) also

suggest that in an actual pandemic situation,

program management should not minimize

the threat. In addition, staff members should 

be encouraged to develop pandemic-specific

emergency plans for their own households. 

Planning Assumptions for Pandemic 

Influenza 

When drafting the Pandemic Appendix, the

first step is to identify planning assumptions

for pandemic influenza. These assumptions,

based on available data and information 

from public health authorities, form the basis

for planning decisions. Exhibit 6-5 provides

examples of planning assumptions. 

Drafting and Activating the 

Pandemic Plan 

The Pandemic Appendix should state who

determines when the plan is activated

because of pandemic conditions, what

information will be used to make the 

decision to activate the plan, and the

modified policies and procedures that will

be implemented. The appendix also should

describe actions that will be taken if essential 

services cannot be provided because of staff

shortages, quarantine, facility closures, or 
Chapter 6—Planning Issues for Pandemic Influenza

Exhibit 6-5. Examples of Pandemic Influenza Planning Assumptions 

Issue Assumptions 

Time Factors 

The time interval between an alert issued for pandemic influenza and its arrival in the 

community may be short or long (ranging from days to months). 

The pandemic may last as long as 18 months and occur in several waves, with mortality and 

morbidity increasing and decreasing sporadically. 

Waves of severe disease may last 1–4 months. 

Prevention 

and 

Treatment of 

the Influenza 

A vaccine may not be available for many months after an influenza pandemic begins, and 

supplies of it may be limited. 

Antivirals may not treat or protect against the pandemic influenza virus strain. 

Even if effective, antiviral medications may be in limited supply, and their distribution may 

occur in phases. 

Infection control strategies and social distancing strategies (e.g., postponing public 

gatherings such as support group meetings, substituting Internet and phone counseling for 

in-person sessions) can be used to slow the spread of disease. 

Isolation of ill people will be required. 

Quarantine of healthy people exposed to ill people may be implemented. 

Clients 

and Staff 

Members 

Clients with weakened immune systems or who are pregnant are at higher risk for severe 

illness and death. 

Twenty to fifty percent absenteeism for staff, clients, vendors, and services within the 

community may occur. Absenteeism will be the result of staff members and clients becoming 

ill, staying home to care for children or family members, or refusing to go to the facility for 

fear of contracting the virus. 

Every person who becomes ill is likely to miss from a few days to many weeks of work. 

In a severe pandemic, 0.1 percent–2.5 percent of people who become ill may die. 

Staff members and clients (including residential patients) may develop symptoms while on 

program premises. 

Staff members may be asked to perform tasks that are not part of their normal job 

descriptions, to provide coverage for essential services; alternatively, they may be transferred 

to other duties or facilities where coverage is needed, or they may be assigned to work 

extended or additional shifts. 

In a severe pandemic, essential staff members may be drafted into the care of the sick, and 

residential facilities may be commandeered to create pandemic wards separate from the 

main hospitals. 

In a severe pandemic, fear and anxiety levels will increase. 

Services 

Services will be stressed but will remain functional. 

Telecommuting practices may be implemented for support services (e.g., administrative 

functions). 

Critical functions carried out by contractors, consultants, and vendors may be erratic. 

The program may be unable to rely on mutual aid resources to support its response efforts. 

Staff may accrue an unbudgeted amount of overtime or use higher-than-normal amounts of 

leave and sick time. 

Excerpted and adapted from San Francisco Department of Public Health (2006, p. 6). 

71 
Disaster Planning Handbook for Behavioral Health Treatment Programs

72 

other pandemic-related events, and it should

describe the conditions under which the plan

will be deactivated and staff will return to 

normal duties. 

The local public health department is a

primary source of information about local

pandemic conditions, and CDC provides

continuously updated information on

conditions nationwide. 

The decision to activate the pandemic plan

must be made carefully. The hardships

imposed by reducing or modifying services

to clients must be weighed against the

risks of infection. If pandemic procedures

are activated too soon, the hardships will

outweigh the benefits and adherence (such as

to social distancing procedures) may wane.

However, if procedures are activated too

late, the infection prevention benefits may be

limited. 

The program’s Pandemic Appendix should

detail how staff members, clients, and 

the public will be notified of changes in

service provision and procedures including

closings and alternative options for seeking 

assistance. This notification plan will

likely not differ significantly from those

for other types of emergencies. Model text

for notification messages can be composed

in advance and included in the Pandemic 

Appendix. Examples of message objectives

include: 

• Informing staff and clients of pandemic

conditions. 

• Counteracting rumors and misinformation. 

• Providing basic situational anxiety

management information and suggested

techniques (e.g., deep breathing, relaxation

techniques, keeping hydrated). 

• Providing staff members with a resource

for their confidential use (e.g., an employee

assistance program) that can help them

with pandemic-related challenges. 

• Providing information on the general

health conditions of colleagues and clients

(including notifications of death). 

• Providing referral to bereavement

counseling and other social supports. 
73 

Chapter 7—Completing, Testing, 

Activating, and Deactivating the Plan 

In This Chapter 

• Assemble the Plan 

• Distribute the Plan 

• Train and Test 

• Activate the Plan in Disaster 

• Deactivate and Revise the 

Plan 

• Coordinate With the 

Community in Recovery 

• Support Staff Members,

Clients, and Community

After the Disaster 

• Continuously Revise and

Update the Disaster Plan 

Worksheets (see Appendix B) 

• B1 Checklist for the Written 

Disaster Plan 

• B20 Disaster Plan Training

and Testing Log 

As explained in Chapter 1, the behavioral health

treatment program’s disaster planning team drafts

the sections of the written disaster plan as it gathers

information based on a risk assessment document; the 

team recommends to management implementation

options (following the processes outlined in Chapters

2 through 6). This chapter explains the steps involved

in completing and working with the plan. These steps

include assembling and distributing the plan, training

staff on using it, testing the plan, activating the plan

when a disaster incident occurs, deactivating the plan

when the state of emergency ends, revising the plan

based on lessons learned from the disaster response,

and providing support to staff and clients after the

disaster. 

Assemble the Plan 

When all sections of the disaster plan are completed,

they can be assembled into one document. Worksheet 

B1 (in Appendix B) provides a checklist of all items

that should be included in the plan. The following

elements are inserted at the front, or Preface, of the 

document: 

•	 Cover page . Include the title, date, and facility

covered by the plan. 

•	 Signature page . This page includes signatures of

the program’s executive director and other senior

managers (e.g., the chair of the program’s board of

directors) that affirm that the program’s leadership

approves and endorses the plan. Management can

sign off on sections as they are completed or at one

time on the entire document. 

•	 Title page . This page includes placeholders to

record the date of changes and revisions to show

that the plan is being kept current and to indicate

that the document is the current version. 

•	 Record of changes . This record indicates changes

that were made to the plan and the dates they were

made. 
Disaster Planning Handbook for Behavioral Health Treatment Programs

74 

•	 Record of distribution . This page

indicates who has received a copy and

where other copies are stored (e.g., in the

facility go kit). 

•	 Table of contents . A list of the sections 

in the plan (as well as a tabbed page at

the start of each section) helps users find

information quickly. 

Distribute the Plan 

Once management approves the plan, the

disaster planning team should distribute it to

all relevant parties. Staff members assigned

responsibilities under the plan can receive the

full document or the sections relevant to their 

duties, and they can be given two copies—one

for the office and one for home. The disaster 

planning team can develop a managementapproved summary to provide to other

staff members. The team also can provide

copies of the summary or the full plan, as

appropriate, to the State agency that oversees

behavioral health disorder treatment and to 

other organizations with which the program

has developed relationships for disaster

response (e.g., the local departments of health

and social services, the local jurisdictional

emergency managers, the local chapter of the

American Red Cross). 

Train and Test 

In an actual disaster, no one has time to read 

a disaster plan. Training and testing staff

members familiarize them with procedures so

that they can respond efficiently when and if

a disaster does occur, using the written plan

as a reference. 

Disaster exercises can help staff members

build the skills and teamwork they will

need when executing a disaster plan. These

activities also identify problems or gaps in

the plan that should be addressed, as well as

actions that can mitigate risk. These drills

and exercises may involve staff from, and take

place within, a single facility. Alternatively,

they may encompass the multiple facilities of 

one organization or unaffiliated programs that

are geographically close. Behavioral health

treatment programs may consider providing

staff with compensated time for training

conducted outside regular working hours and

other incentives to enhance disaster readiness 

skills. Disaster-related courses are offered 

by the Emergency Management Institute of

the Federal Emergency Management Agency

(FEMA) and by local chapters of the American

Red Cross. Worksheet B20 (in Appendix B)

can be used to log training and testing activities. 

Each training exercise should build on the

previous one (FEMA, 2009). Types of exercises

are summarized in the following sections. 

Discussion-Based Seminars 

Training can begin as the disaster plan is

being developed. With the support of senior

management, the disaster planning team can

schedule briefings to familiarize staff with

basic disaster concepts and staff roles and

to build support for the disaster readiness 

concept. 

Discussion-Based Workshops 

Through facilitated discussions, staff can

provide input on the disaster plan and the

policies that would support the plan, draft

specific sections of the written plan, and develop

supporting products, such as job-related aids. 

Tabletop Exercise 

A tabletop exercise provides initial training

to key staff members who are responsible for

executing the disaster plan. In a classroom

setting, a scenario is presented by a facilitator,

and participants talk through possible

responses (FEMA, 2009). New developments

in the scenario are presented during the

exercise so that participants reconsider

previous decisions and plan their next actions.

Participants share ideas and discuss options

for responding to the hypothetical situation,

without the pressures that occur in a real

or simulated event. The tabletop exercise

familiarizes participants with their roles and 
Chapter 7—Completing, Testing, Activating, and Deactivating the Plan

responsibilities and reveals issues that require

revision or additional planning. Tabletop

exercises also enable local organizations to

network and share ideas on improving disaster

readiness. Exhibit 7-1 summarizes a tabletop

exercise involving opioid treatment programs

(OTPs) in King County, WA. Exhibit 7-2

provides an example of the useful networking

that can occur at a tabletop exercise. 

Functional Exercise 

In a functional exercise, participants act out

responses according to their assigned roles

in a simulated disaster scenario rather than 

simply discuss potential responses. This roleplay places participants under time pressure. 

The simulation evolves over time; for example,

the scenario might start as a wildfire that is

followed by a rainstorm and landslide. 

As its name implies, the functional exercise

typically tests a function rather than the

entire breadth of activities that would be 

engaged in a real disaster. For example, an

exercise might focus on one of the following: 

• Coordination of staff members from two 

behavioral health treatment programs for the

transfer of clients from one facility to another 

• Communicating during a severe pandemic

with clients who have limited English

proficiency 

Exhibit 7-1. Tabletop Exercise for Opioid Treatment Programs (1.5 hours) 

Element Description 

Participating 

Organizations 

City of Seattle Office of Emergency Management 

Drug Enforcement Administration (DEA) 

Evergreen Treatment Services 

King County Healthcare Coalition 

Public Health—Seattle and King County 

Therapeutic Health Services 

University of California, Los Angeles 

Veterans Administration (Washington State Department of Veterans Affairs) 

Washington State Board of Pharmacy 

Washington State Division of Alcohol and Substance Abuse 

Exercise 

Objectives 

Determine ability to support timely decisions about operations of OTPs in an emergency 

Demonstrate ability to coordinate communication and resources among key stakeholders 

Evaluate process for activating mutual aid agreements among OTPs 

Discuss protocols and rules of regulatory agencies 

Scenario 

Timeline and 

Major Events 

Friday, May 29, 7:59 a.m.: A very large earthquake occurred, rumbling through the entire 

Puget Sound region for 2 minutes. Damage is visible in the entire county. All landline and 

cell phones are jammed. Electricity is out in the neighborhoods of SODO, Capitol Hill, and 

First Hill. 

Friday, May 29, 8:45 a.m.: Media report a shallow 6.8 magnitude earthquake occurred in the 

Black Diamond area and extensive damage in Kent, Auburn, and Renton. The 520 bridge 

has collapsed. The Alaskan Way viaduct is closed. 

Saturday, May 30: Landline and cell phones work sporadically. Text messages are getting 

through. Limited power returns to SODO region. Evergreen Treatment Services has power 

but no water. 

Monday, June 1: President signs a disaster declaration for the area. 

Monday, July 6: Several moderate aftershocks (2–5 in magnitude) have occurred since May 29. 

Continued on next page 

75 
Disaster Planning Handbook for Behavioral Health Treatment Programs

Exhibit 7-1. Tabletop Exercise for Opioid Treatment Programs (continued) 

Element Description 

Lessons 

Learned 

OTPs that have generators will assess what equipment, including alarms and medication 

storage areas, are powered by their agencies’ backup generator. 

OTPs will advise staff members that they should plan alternate routes to work. 

OTPs will work on strategies for communicating with staff members, patients, and the 

general public, including the media, in a disaster. This includes developing communication 

strategies for contacting patients if power is down and landline and cell phones are 

jammed and encouraging staff members to have an out-of-area phone contact. 

OTPs will work on developing strategies for communicating with one another about their 

ongoing activities in a disaster. 

OTPs that anticipate a need for enhanced services in a disaster (e.g., heightened security, 

priority in restoring power, transportation considerations) should immediately contact their 

local Emergency Operations Center for guidance on addressing problems identified during 

the exercise. The contact at the Emergency Operations Center should be at least at the 

level of captain. 

Local OTPs may need to coordinate with OTPs outside King County. Although nothing is 

currently in place to enable that process, the use of the existing mutual aid agreement as a 

template for working with OTPs in other counties is encouraged. 

A State-level entity would be most appropriate to take the lead in facilitating emergency 

preparedness activities among OTPs across the State. 

To balance the needs of patient access to medication, patients’ and staff members’ physical 

safety, security of medication, and provider’s liability exposure, OTPs will need support from 

regulatory authorities. 

DEA wants OTPs to keep it apprised of their activities in a disaster but does not want to 

impede program activities. DEA will provide OTPs with an emergency contact telephone 

number. 

The King County jail needs a disaster plan for dosing methadone patients if a licensed OTP 

is unable to do so. 

Verification is needed as to whether general population shelter operators will allow patients to 

bring take-home doses of methadone into the shelter, even when prescriptions can be verified. 

A medically based disaster plan is needed to address citizens who are chronically 

intoxicated and/or who abuse opioids and are suddenly cut off from their substance of 

choice because of the disaster. 

Excerpted and adapted from King County Healthcare Coalition (2009). 

Exhibit 7-2. Beneficial Networking at a Tabletop Exercise 

Various community agencies and organizations participating in a tabletop exercise can exchange useful 

information that might otherwise not be shared. During the tabletop exercise described in Exhibit 

7-1, discussion turned to the use of generators for emergency power. The manager of an emergency 

responder agency indicated that OTPs might be able to obtain priority fuel assistance for their 

generators during an outage. This advice was useful to the OTP administrators, because lines at gas 

stations can be long during an emergency. One administrator who had experienced a communitywide 

extended power outage after a storm reported that he had had to divert staff members from their 

treatment functions to the task of finding gas: “I’d load them up with gas cans and send them out to fill 

them all up, so we’d have fuel for a couple of days.” 

Source: Podus et al. (no date). 

76 
Chapter 7—Completing, Testing, Activating, and Deactivating the Plan

77 

 

• Notifying families and referral agencies

during an emergency evacuation at an

adolescent residential treatment program 

• Executing a plan for sheltering-in-place

that provides for the unique needs of

populations defined as at-risk (U.S.

Department of Health and Human

Services [HHS], 2012) 

Typically, it will be more feasible, costeffective, and productive for a behavioral

health treatment program to participate in

a community-sponsored functional exercise

than to conduct one on its own. The disaster 

planning team that has an established

working relationship with local emergency

planners, as described in Chapter 2, can

stay apprised of when such exercises are

scheduled and find out how to arrange for

program staff members to participate. 

Field Exercise 

A field exercise is a full-scale enactment of 

a disaster, with people acting out their roles

in real time, using actual equipment, and

testing multiple emergency functions. A field

exercise takes a great deal of planning, is

disruptive to normal business operations,

and is expensive. Thus, a behavioral health

treatment program is unlikely to conduct

this kind of exercise on its own. However, 

its staff can benefit from participating in a

field exercise organized by local or regional

emergency management leaders. 

Although community field exercises can

be beneficial, behavioral health treatment 

programs do not have a strong record of

participating in such efforts. A survey of 90

OTPs found that, whereas all responding OTPs

had disaster plans and participated in tabletop

and functional exercises of their plans, less

than 17 percent had partnered with another

agency for a field exercise (Podus, 2009). Less

than 30 percent reported that they knew “a

good deal” about how local government and

community agencies (e.g., mental health

services providers, law enforcement, emergency

management, the American Red Cross) would

handle circumstances related to a disaster 

in their areas. Leaders of behavioral health 

treatment programs should actively network

with local emergency managers so that the

leaders are aware of joint exercises, can testify

to the importance of being included in the

planning and execution of these exercises, and

are invited to be involved. 

Evaluation is an integral part of any training 

exercise, whether a tabletop or a full functional 

exercise. Decisions on exercise goals and how 

to evaluate these goals should be decided 

upon at the beginning of the process. Effective 

exercise planning begins with setting these 

measurable goals. The exercise itself ends 

with a measurement of success in achieving 

those goals, which leads to decisions that may 

include how to improve the current disaster 

plan, policies, and trainings. The resulting 

document is referred to as an After-Action Plan 

and includes improvement goals, objectives, 

responsible parties, and timelines for making 

these improvements. FEMA’s Homeland 

Security Exercise and Evaluation Program 

is a tool for developing training exercises 

and establishing and evaluating the exercise 

goals. This tool can be scaled up or down 

for exercises of all sizes and types, and it can 

modified based on the needs of the program. 

It is located at https://www.llis.dhs.gov/hseep. 

Activate the Plan in Disaster 

When a disaster occurs, swift mobilization 

can lessen the impact. Through the process

of testing and training, staff can become

familiar with the four key steps to take in

disaster response. These are: 

1. Activate the program’s Incident Command

System (a key person is designated Incident

Commander to manage response; see

Designate Personnel To Assume Command

for Incident Response, Chapter 3). 

2. Decide on objectives and priorities to

minimize risk to persons and property,

based on the nature of the incident (e.g.,

if a wildfire is approaching a program, the

first priority will be immediate evacuation

of the facility and a second priority will 
Disaster Planning Handbook for Behavioral Health Treatment Programs

 

 

be protection of property). The disaster

plan’s hazard-specific appendices provide

guidance on objectives for response to a

specific threat, such as a wildfire. 

3. Create an Incident Action Plan to accomplish

the objectives in a specified timeframe.

The plan will indicate assignments and the

resources that can be used to complete those

assignments. An informal draft can suffice

unless the incident response is expected to be

large and complex. 

4. Follow through on the plan, except where

it is necessary to make modifications to the

plan to address changing circumstances. 

Familiarity with disaster procedures helps

leaders activate a disaster response at the right

time—not too soon, too late, or unnecessarily.

Exhibit 7-3 illustrates timing ramifications.

Two key variables affect the decisionmaking

process: (1) whether the program has received

advance notice of the disaster, and (2) when

the incident occurs (during or after business

hours). A hurricane or severe blizzard

usually allow for advance notice, whereas

an earthquake or hazardous materials spill

typically will not. Disaster incidents that

occur when key staff members are off duty or

are out of town may require subordinate staff 

members to make decisions on when and how 

to contact their supervisors and on the actions

to take. Recurrent disaster training for all staff

members and clarity about succession planning

are the best protections against a sudden

disaster that occurs when senior management

staff members are not present. Training for

management and staff can be offered in short

sessions over time and build from basic to more 

advanced skills, based on roles. This kind of 

graduated training schedule avoids disruption

of treatment services. 

Deactivate and Revise the Plan 

Deactivation is the process by which an

organization ends its state of emergency and

resumes normal operations. Examples of

deactivation activities for a behavioral health 

treatment program include: 

• Returning from an alternate facility to the

home location after the disaster incident 

has passed, such as when a mandatory

evacuation has ended. (Among disaster

response planners, this return is called 

reconstitution [FEMA, 2004].) 

• Contacting outpatient clients to inform

them that counseling services have 

Exhibit 7-3. Effect of Timing Decisions on Staff 

Nurses are key personnel in OTPs. In an impending disaster such as a blizzard or hurricane, they are 

often among the last to leave the premises because they are the ones who provide patients with 

emergency take-home medications. 

In a disaster, the treatment program must request, and receive approval for, any needed dispensing 

exceptions from the Center for Substance Abuse Treatment’s Division of Pharmacologic Therapies. 

Carrying out a decision to provide emergency doses can take up to 72 hours after approval has been 

obtained, according to providers who have been through weather-related emergencies. That much time 

may be necessary for notifying patients, for patients to reach the clinic during business hours, and for 

the providers to dispense the medication. 

“Sometimes I wish they would just let us know a little bit sooner,” reported a nurse who has worked 

during several weather-related emergencies. She recalled one situation in which she stayed to dispense 

medication so long that “on our drive home, the wind force was really bad. . . . I could feel my car 

going like this [gestures]. I’m really having to hold my car in the road. I would like to see them maybe 

make a decision a little bit sooner. . . . I mean, you know, [it] would be a little bit more safe for us, too, 

as the employees.” 

Source: Podus et al. (no date). 

78 
Chapter 7—Completing, Testing, Activating, and Deactivating the Plan

79 

resumed a regular schedule and to

reschedule appointments, as needed. 

• Encouraging clients to reengage in services

by having their assigned counselors

contact them by phone about additional

services or referrals, as needed. 

• Arranging for the return of patients on

methadone maintenance who have received 

guest dosing at another facility (and the

retrieval of records related to this treatment). 

• Completing reconstruction of all or part of

a facility that had been destroyed. 

After deactivation, designated disaster

planning team members should debrief staff

to obtain a complete picture of the program’s

response throughout the incident. Based on this

information, the team may be able to identify

steps it can take to improve future preparedness

and response. With the approval of senior

management, the team can update or revise the

plan and retest it to ensure that the corrective

actions are workable and appropriate. 

When a disaster occurs or when a training

exercise is completed, the disaster response

leadership prepares an After-Action Report.

This report summarizes the event, lists the

strengths and weaknesses of the response, and

presents lessons learned. Based on this report, 

an After-Action Plan is prepared. The plan is

often presented in table format and identifies

goals and objectives, due dates for completion

of tasks, and the responsible parties for

completing each objective. Depending on

the kind of incident that has occurred, the 

recovery phase guided by an After-Action Plan

can last weeks, months, or longer. 

Adequate planning and training for

disaster can expedite the recovery time.

Staff should be encouraged to follow the

disaster plan’s recovery procedures (e.g.,

for contacting insurance representatives,

collecting necessary documentation, filing

claims, applying for recovery grants and

aid, recording recovery expenses). A system

should also be in place to allow staff members

to record their extended hours of duty during

and after the disaster so that they can be

duly compensated and recognized. Exhibit 7-4

provides examples of recovery steps. 

Coordinate With the Community 

in Recovery 

The behavioral health treatment program’s

involvement with its community’s recovery

may be governed by the extent to which it

engaged in predisaster recovery planning 

Exhibit 7-4. Examples of Recovery Steps 

• Keep staff members and clients away from debris, floodwaters, and damaged property; do not allow 

reentry to the building until permitted by the program’s security officer or other officials. 

• Prioritize and address needed repairs to damaged buildings and grounds, and take necessary steps to 

prevent new hazardous incidents (e.g., address erosion caused by a storm so that basement flooding 

does not occur). 

• Inform staff of procedures for documenting recovery steps and expenses to facilitate reimbursements. 

• Arrange for inspections by certified safety specialists as required by circumstances. 

• Clean, disinfect, or discard wet items to avoid mold. 

• Ventilate and clean shelter areas. 

• Restock emergency supplies. 

• Reimburse and thank providers of aid and emergency supplies. 

• Evaluate the disaster response and recovery, and use this evaluation to update the disaster plan. 

• Provide avenues to inform staff of any updates to the disaster plan. 
Disaster Planning Handbook for Behavioral Health Treatment Programs

and other recovery preparedness, mitigation,

and community resilience-building work (see

Chapter 2). Community recovery is managed

by local governments, in conjunction with

nongovernmental partners and stakeholders

and with State and Federal agencies.

Behavioral health treatment programs

are most likely to become involved via the

Health and Social Services Recovery Support

Function, as defined by the National Disaster 

Recovery Framework (U.S. Department of

Homeland Security, 2011a).* 

Appendix B of the National Disaster Recovery 

Framework includes predisaster and 

postdisaster checklists and planning activities 

by sector, including private and nonprofit 

sectors. They can be accessed at: http://www. 

fema.gov/pdf/recoveryframework/ndrf.pdf. 

Support Staff Members, Clients, 

and Community After the Disaster 

The emotional well-being of staff is an

important consideration throughout the

disaster recovery phase. Stress management

mechanisms (e.g., regular rather than

overtime shifts as much as possible,

compensatory time for personal recovery

needs) can be built into the recovery action

plan to reduce the psychological burdens

for staff. Staff members should always be

referred outside the program for assessment

or treatment of personal stress reactions

related to the disaster (this does not refer to

incident briefings or debriefings that are part

of the program’s efforts to share information

during disaster response and recovery).

One option for providing staff support is to

contract with a local employee assistance

program for these services. Traumatized

mental health professionals should be able

to resume their normal duties when they are

no longer symptomatic, but such decisions

need to be made on an individual basis by the

administrator, the clinical supervisor, and the 

person involved. Professionals who claimed

disability benefits also will need permission

to return to duty from their physicians or

therapists. 

The Disaster Distress Helpline is the Nation’s 

first hotline dedicated to providing disaster 

crisis counseling. The Helpline operates 

24 hours a day, 7 days a week. This free, 

confidential, and multilingual crisis support 

service is available via telephone (1-800-985­

5990) and SMS (text TalkWithUs to 66746) to 

U.S. residents in psychological distress due 

to natural or human-caused disasters. Callers 

are connected to trained crisis counseling 

professionals. The Helpline staff provides 

confidential counseling, referrals, and other 

needed support services. Information on the 

Helpline is available at http://disasterdistress. 

samhsa.gov. 

Clients can benefit from extra support (e.g.,

educational sessions, pertinent handouts,

additional counseling sessions, access to

a crisis hotline) to help them maintain

recovery following a major calamity. The

program can provide clients with a list of

recovery resources that has been updated

after the disaster to reflect changes in

organizations, locations, meeting dates,

and times. The program also may take on

other activities to support the mental and

substance use disorder recovery communities

(e.g., arranging for translation services at

meetings of mutual-help groups, organizing

transportation to those meetings, providing

space for a meeting at the facility, ensuring

that mutual-help groups are available

for specific populations such as those

with co-occurring disorders or those with

pharmacological dependency). 

Finally, through its participation in the

community’s coordinated disaster recovery,

the behavioral health treatment program

should stay alert to the needs of the local

community after the disaster. The program

may be able to offer targeted assistance; 

*

This Recovery Support Function is coordinated by the Office of the Assistant Secretary for Preparedness and

Response, HHS. 

80 
81 

Chapter 7—Completing, Testing, Activating, and Deactivating the Plan 

for example, it may be able to partner with

other agencies to offer SBIRT services—

screening, brief intervention, and referral

to treatment of mental, substance use, or 

co-occurring disorders (Substance Abuse

and Mental Health Services Administration, 

2011b). SBIRT assessments can be offered

on quarterly or yearly anniversaries of the

disaster or as requested. Programs may

want to be especially proactive about offering

SBIRT services to community members who

were directly affected by the disaster or who

were involved in response efforts (e.g., police,

firefighters, search-and-rescue volunteers,

shelter staff, members of the media who 

reported on the disaster). 

Continuously Revise and Update 

the Disaster Plan 

The development, planning, and testing

cycles of any good disaster plan are ongoing.

After every test and every activation—and

in tandem with any significant change to 

the program’s services or facilities—the plan

must be reviewed, evaluated, and updated.

This cycle is continuous and ever challenging,

requiring resources and commitments

from leadership and the whole staff. Yet

the benefits of disaster preparedness and

planning for behavioral health programs,

clients, and staff cannot be underestimated. 

The effort that goes into continuous disaster

planning can save lives and mitigate the

long-term impact of disaster on those whom

the program serves. 

Appendix A—Bibliography
 

American Medical Association. (2005). Meeting the mental health needs of victims, families,

and responders. In Management of public health emergencies: A resource guide for 

physicians and other community responders (Section 9). Retrieved June 20, 2013, from

https://www.firstrespondertraining.gov/content/publications/AMAEMER/09.%20Mental%20

Health.pdf 

American Red Cross. (2009). Be Red Cross Ready. Retrieved June 20, 2013, 

from http://arcbrcr.org/ 

Barnett, D. J., Balicer, R. D., Thompson, C. B., Storey, J. D., Omer, S. B., Semon, N. L., et

al. (2009). Assessment of local public health workers’ willingness to respond to pandemic

influenza through application of the extended parallel process model. PLoS One, 4(7), e365. 

Bethel, J. W., Foreman, A. N., & Burke, S. C. (2011). Disaster preparedness among medically

vulnerable populations. American Journal of Preventive Medicine, 40(2), 139–143. 

Cepeda, A., Saint Onge, J. M., Kaplan, C., & Valdez, A. (2010). The association between

disaster-related experiences and mental health outcomes among drug using African

American Hurricane Katrina evacuees. Community Mental Health Journal, 46(6), 612–620. 

Cepeda, A., Valdez, A., Kaplan, C., & Hill, L. E. (2010). Patterns of substance use among

Hurricane Katrina evacuees in Houston, Texas. Disasters, 34(2), 426–446. 

Cerdá, M., Tracy, M., & Galea, S. (2011). A prospective population based study of changes

in alcohol use and binge drinking after a mass traumatic event. Drug and Alcohol 

Dependence, 115(1–2), 1–8. 

Cloyd, E., & Dyer, C. B. (2010). Catastrophic events and older adults. Critical Care Nursing 

Clinics of North America, 22(4), 501–513. 

Dewart, T., Frank, B., Schmeidler, J., Robertson, K., & Demirjian, A. (2003). The impact of 

9/11 on New York City’s substance abuse treatment programs: A study of patients and 

administrators. Albany, NY: New York State Office of Alcoholism and Substance Abuse

Services. 

Edgington, S. (2009). Disaster planning for people experiencing homelessness. Nashville, TN: 

National Health Care for the Homeless Council. 

Federal Emergency Management Agency. (2004). Interim guidance on continuity of operations 

planning for state and local governments. Washington, DC: U.S. Department of Homeland

Security. 

Federal Emergency Management Agency. (2006). NIMS implementation activities for hospitals 

and healthcare systems. Washington, DC: U.S. Department of Homeland Security. 

83 
Disaster Planning Handbook for Behavioral Health Treatment Programs

84 

Federal Emergency Management Agency. (2007a). Robert T. Stafford Disaster Relief and 

Emergency Assistance Act, as amended, and related authorities (FEMA 592). Retrieved June 

21, 2013, from: http://www.fema.gov/pdf/about/stafford_act.pdf 

Federal Emergency Management Agency. (2007b). IS-100HC: Introduction to the Incident 

Command System for healthcare/hospitals [Online course]. Washington, DC: U.S.

Department of Homeland Security. 

Federal Emergency Management Agency. (2007c). IS-546.a: Continuity of operations awareness

[Online course]. Washington, DC: U.S. Department of Homeland Security. 

Federal Emergency Management Agency. (2008). National Response Framework Resource 

Center glossary/acronyms. Washington, DC: U.S. Department of Homeland Security.

Retrieved June 21, 2013, from http://www.fema.gov/pdf/emergency/nrf/nrf-glossary.pdf 

Federal Emergency Management Agency. (2009). IS-120.a: An introduction to exercises [Online

course]. Washington, DC: U.S. Department of Homeland Security. 

Federal Emergency Management Agency. (2010a). Comprehensive preparedness guide: 

Developing and maintaining emergency operations plans (Version 2.0). Washington, DC:

U.S. Department of Homeland Security. 

Federal Emergency Management Agency. (2010b). Guidance on planning for integration of 

functional needs support services in general population shelters. Washington, DC: U.S.

Department of Homeland Security. 

Federal Emergency Management Agency. (ca. 2011). Multihazard emergency planning for 

schools toolkit: Glossary. Washington, DC: U.S. Department of Homeland Security.

Retrieved June 21, 2013, from http://www.training.fema.gov/EMIWeb/emischool/

EL361Toolkit/glossary.htm 

Homeland Security Council. (2005). National strategy for pandemic influenza. Washington, DC:

Author. 

Hughes, F. A. (2010). H1N1 pandemic planning in a mental health residential facility. Journal 

of Psychosocial Nursing and Mental Health Services, 48(3), 37–41. 

Hutchins, S. S., Fiscella, K., Levine, R. S., Ompad, D. C., & McDonald, M. (2009). Protection

of racial/ethnic minority populations during an influenza pandemic. American Journal of 

Public Health, 99(S2), S261–S270. 

King County Healthcare Coalition. (2009). Opioid substitution programs earthquake tabletop: 

After action report & improvement plan. PDF file downloaded June 20, 2013, from http://

www.kingcounty.gov/healthservices/health/preparedness/hccoalition/%7e/media/health/

publichealth/documents/hccoalition/OTPTTXAAR.ashx 

Laditka, S. B., Murray, L. M., & Laditka, J. N. (2010). In the eye of the storm: Resilience and

vulnerability among African American women in the wake of Hurricane Katrina. Health 

Care for Women International, 31(11), 1013–1027. 
85 

Appendix A—Bibliography 

Lavin, R. & Menifee, S. (Eds.). (2009). Disaster case management: Implementation guide. 

Washington, DC: Administration for Children and Families, U.S. Department of Health

and Human Services. 

Mace, S. E., Sharieff, G., Bern, A., Benjamin, L., Burbulys, D., Johnson, R., & Schreiber, M.

(2010a). Pediatric issues in disaster management, part 2: Evacuation centers and family

separation/reunification. American Journal of Disaster Medicine, 5(3), 149–161. 

Mace, S. E., Sharieff, G., Bern, A., Benjamin, L., Burbulys, D., Johnson, R., & Schreiber, M.

(2010b). Pediatric issues in disaster management, part 3: Special healthcare needs patients

and mental health issues. American Journal of Disaster Medicine, 5(5), 261–274. 

Martel, L. D., & Mueller, C. W. (2011). The effect of anticipated service interruptions on

disaster preparedness intentions. Journal of Applied Social Psychology, 41(2), 298–311. 

Maxwell, J. C., Podus, D., & Walsh, D. (2009). Lessons learned from the deadly sisters: Drug

and alcohol treatment disruption, and consequences from Hurricanes Katrina and Rita. 

Substance Use and Misuse, 44(12), 1681–1694. 

Meredith, L. S., Eisenman, D. P., Tanielian, T., Taylor, S. L., Basurto-Davila, R., Zazzali, J., et 

al. (2011). Prioritizing “psychological” consequences for disaster preparedness and response:

A framework for addressing the emotional, behavioral, and cognitive effects of patient surge

in large-scale disasters. Disaster Medicine and Public Health Preparedness, 5(1), 73–80. 

Meredith, L. S., Zazzali, J. L., Shields, S., Eisenman, D. P., & Alsabagh, H. (2010).

Psychological effects of patient surge in large-scale emergencies: A quality improvement

tool for hospital and clinic capacity planning and response. Prehospital and Disaster 

Medicine, 25(2), 107–114. 

Murray, J. S. (2010). Responding to the psychosocial needs of children and families in disaster. 

Critical Care Nursing Clinics of North America, 22(4), 481–491. 

National Biodefense Science Board, Disaster Mental Health Subcommittee. (2010). Integrating 

behavioral health in federal disaster preparedness, response, and recovery: Assessment and 

recommendations. Retrieved June 20, 2013, from http://www.phe.gov/Preparedness/legal/

boards/nbsb/meetings/Documents/dmhreport.pdf 

National Center for State Courts. (2007). Continuity of court operations: Steps for COOP 

planning. Washington, DC: Bureau of Justice Assistance. 

National Council on Disability. (2006). The needs of people with psychiatric disabilities during 

and after Hurricanes Katrina and Rita: Position paper and recommendations. Retrieved 

June 20, 2013, from http://www.power2u.org/katrina/needs.html 

National Fire Protection Association. (2007). NFPA 1600, standard on disaster/emergency 

management and business continuity programs. Quincy, MA: Author. 

National Institute on Drug Abuse. (1997). Drug abuse prevention: What works. NIH Publication 

No. 97-4110. Retrieved June 20, 2013, from http://www.idt.pt/PT/Prevencao/Documents/

PIF/drug_abuse_nida.pdf 
Disaster Planning Handbook for Behavioral Health Treatment Programs

86 

North, C. S. (2010). A tale of two studies of two disasters: Comparing psychosocial responses

to disaster among Oklahoma City bombing survivors and Hurricane Katrina evacuees. 

Rehabilitation Psychology, 55(3), 241–246. 

Occupational Safety and Health Administration. (2009). Guidance on preparing workplaces for 

an influenza pandemic. OSHA 3327-05R 2009. Washington, DC: Author. 

Office for Civil Rights. (2005). Hurricane Katrina bulletin: HIPAA privacy and disclosures in 

emergency situations. Washington, DC: U.S. Department of Health and Human Services. 

Office of the Assistant Secretary for Preparedness and Response. (2012). Hospital preparedness 

program overview: FY02 to present and beyond. Retrieved June 20, 2013, from 

http://www.phe.gov/Preparedness/planning/hpp/Pages/overview.aspx 

Picou, J. S., & Hudson, K. (2010). Hurricane Katrina and mental health: A research note on

Mississippi Gulf Coast residents. Sociological Inquiry, 80(3), 513–524. 

Podus, D. (2009). Disaster planning and opioid treatment programs. The Dialogue, 5(3), 6–8. 

Podus, D., Maxwell, J., & Anglin, M. D. (no date). Disaster planning for disruptions in 

methadone treatment. Unpublished study, National Institute on Drug Abuse and the Robert

Wood Johnson Foundation’s Substance Abuse Policy Research Program. 

Rabins, P. V., Kass, N. E., Rutkow, L., Vernick, J. S., & Hodge Jr., J. G. (2011). Challenges

for mental health services raised by disaster preparedness: Mapping the ethical and

therapeutic terrain. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and 

Science, 9(2), 175–179. 

Rasmussen, S. A., Jamieson, D. J., & Breese, J. S. (2008). Pandemic influenza and pregnant 

women. Emerging Infectious Diseases, 14(1), 95–100. 

Rhodes, J., Chan, C., Paxson, C., Rouse, C. E., Waters, M., & Fussell, E. (2010). The impact

of Hurricane Katrina on the mental and physical health of low-income parents in New

Orleans. American Journal of Orthopsychiatry, 80(2), 237–247. 

Sakauye, K. M., Streim, J. E., Kennedy, G. J., Kirwin, P. D., Llorente, M. D., Schultz, S. 

K., & Srinivasan, S. (2009). AAGP position statement: Disaster preparedness for older

Americans: Critical issues for the preservation of mental health. American Journal of 

Geriatric Psychiatry, 17(11), 916–924. 

San Francisco Department of Public Health. (2006). Pandemic influenza continuity of 

operations guide & template: For San Francisco city and county agencies. San Francisco, 

CA: Author. 

Shin, P., & Jacobs, F. (2012). An HIT solution for clinical care and disaster planning: How one

health center in Joplin, MO survived a tornado and avoided a health information disaster. 

Online Journal of Public Health Informatics, 4(1). doi:10.5210/ojphi.v4i1.3818 

Shiu-Thornton, S., Balabis, J., Senturia, K., Tamayo, A., & Oberle, M. (2007). Disaster

preparedness for limited English proficient communities: Medical interpreters as cultural

brokers and gatekeepers. Public Health Reports, 122(4), 466–471. 
87 

Appendix A—Bibliography 

Stough, L. M., Sharp, A. N., Decker, C., & Wilker, N. (2010). Disaster case management and

individuals with disabilities. Rehabilitation Psychology, 55(3), 211–220. 

Substance Abuse and Mental Health Services Administration. (2005). Psychological first aid 

for first responders: Tips for emergency and disaster response workers. HHS Publication 

No. NMH05-0210. Rockville, MD: Substance Abuse and Mental Health Services 

Administration. 

Substance Abuse and Mental Health Services Administration. (2009). All-hazards disaster

behavioral health: Optimizing psychological health and resiliency in difficult economic

times conference. The Dialogue, 5(4), 1–13. 

Substance Abuse and Mental Health Services Administration. (2011a). Leading change: A plan 

for SAMHSA’s roles and actions 2011–2014. HHS Publication No. (SMA) 11-4629. Rockville,

MD: Substance Abuse and Mental Health Services Administration. 

Substance Abuse and Mental Health Services Administration. (2011b). Screening, brief 

intervention, and referral to treatment (SBIRT). Retrieved June 20, 2013, from 

http://www.samhsa.gov/prevention/SBIRT/index.aspx 

Substance Abuse and Mental Health Services Administration. (2013, April). Federal guidelines 

for opioid treatment. Retrieved July 9, 2013, from http://www.dpt.samhsa.gov/pdf/FederalG

uidelinesforOpioidTreatment5-6-2013revisiondraft_508.pdf 

U.S. Department of Health and Human Services. (2008). Integration of the Medical 

Reserve Corps and the Emergency System for Advance Registration of Volunteer Health 

Professionals (Version 2). Retrieved June 20, 2013, from http://www.medicalreservecorps.

gov/File/ESAR_VHP/ESAR-VHPMRCIntegrationFactSheet.pdf 

U.S. Department of Health and Human Services. (2009a). CDC recommendations for the 

amount of time persons with influenza-like illness should be away from others. Retrieved 

June 20, 2013, from http://www.cdc.gov/h1n1flu/guidance/exclusion.htm 

U.S. Department of Health and Human Services. (2009b). National Health Security Strategy 

of the United States of America. Washington, DC: Office of the Assistant Secretary for

Preparedness and Response. 

U.S. Department of Health and Human Services. (2010). Coping with the Gulf oil spill -

Mental health information. Retrieved June 20, 2013, from http://www.hhs.gov/gulfoilspill/ 

mentalhealth.html 

U.S. Department of Health and Human Services. (2011a). HHS disaster behavioral health 

concept of operations. Washington, DC: Office of the Assistant Secretary for Preparedness

and Response, Office of Policy and Planning, Division for At-Risk Individuals,

Behavioral Health, and Community Resilience. 

U.S. Department of Health and Human Services. (2011b). Public health preparedness 

capabilities: National standards for state and local planning. Atlanta, GA: Division of 

State and Local Readiness, Office of Public Health Preparedness and Response, Centers for

Disease Control and Prevention. 
Disaster Planning Handbook for Behavioral Health Treatment Programs

88 

U.S. Department of Health and Human Services. (2012). At-risk individuals. Retrieved June 

20, 2013, from http://www.phe.gov/Preparedness/planning/abc/Pages/at-risk.aspx 

U.S. Department of Homeland Security. (2008). National Incident Management System. FEMA 

Publication P-501. Washington, DC: Author. 

U.S. Department of Homeland Security. (2011a). National disaster recovery framework: 

Strengthening disaster recovery for the nation. Washington, DC: Author. 

U.S. Department of Homeland Security. (2011b). National Preparedness System, November 

2011. Washington, DC: Author. 

U.S. Department of Homeland Security. (2011c). National preparedness goal (1st ed.).

Washington, DC: Author. 

U.S. Department of Homeland Security. (2013). National response framework (2nd ed.).

Washington, DC: Author. 

Washington State Department of Health and Public Health—Seattle & King County. (2012). 

Frequently asked questions—2012. Retrieved June 20, 2013, from http://www.doh.wa.gov/

Portals/1/Documents/1400/WATracFAQ.pdf 

White House. (2011, March 30). Presidential Policy Directive/PPD-8: National preparedness.

Retrieved June 20, 2013, from http://www.dhs.gov/xlibrary/assets/presidential-policydirective-8-national-preparedness.pdf 

Zagier, A. S. (2011, August 2). Sebelius touts electronic health records in Joplin. New 

Tribune. Retrieved June 20, 2013, from http://www.newstribune.com/news/2011/aug/02/

sebelius-touts-electronic-health-records-joplin 

Zwiebach, L., Rhodes, J., & Roemer, L. (2010). Resource loss, resource gain, and mental health

among survivors of Hurricane Katrina. Journal of Traumatic Stress, 23(6), 751–758. 
89 

Appendix B—Worksheets 

Worksheet B1 Checklist for the Written Disaster Plan 

Worksheet B2 Checklist for Disaster Planning 

Worksheet B3 Checklist of State and Community Representatives and Groups 

Worksheet B4 Checklist of Disaster Planning Discussion Topics 

Worksheet B5 Sheltering-in-Place Checklist 

Worksheet B6 Record of Memoranda of Agreement and Qualified Service Organization

Agreements 

Worksheet B7 Incident Command System Positions 

Worksheet B8 Identify Essential Functions 

Worksheet B9 Identify Essential Staff Positions 

Worksheet B10 Essential Staff Roster 

Worksheet B11 Checklist for Continuity Planning 

Worksheet B12 Requirements for Alternate Facilities 

Worksheet B13 Alternate Facility Arrangements by Disaster Scenario 

Worksheet B14 Checklist for Relocation Planning 

Worksheet B15 Checklist for Maintaining Communications With Essential Groups 

Worksheet B16 Checklist of Records and Databases To Ensure Interoperable Communications 

Worksheet B17 Checklist for Protecting Records and Databases 

Worksheet B18 Checklist for Managing Human Capital 

Worksheet B19 Checklist for Management of Prescribed Medications 

Worksheet B20 Disaster Plan Training and Testing Log 
Worksheet B1 Checklist for the Written Disaster Plan Name Date Instructions: Use with Chapter 1, Rationale and Process for Planning, and Chapter 7, Completing, Testing, Activating, and List the dates that each component of the disaster plan was drafted and compiled into one resource or updated. Component Completed (date) Component Updated (date) Preface Cover page (title, date, and facility covered by the plan) Signature page (with placeholders to record management and, if applicable, board of directo

and confirmation of its official status) Title page (with placeholders to record the dates that reviews/revisions are scheduled/have bRecord of changes (indicating when changes have been made and to which components of thRecord of distribution (including internal and external recipients identified by organization anTable of contents Component Completed (date) Component Updated (date) Basic Plan Statement of purpose and objectives Summary information Planning assumptionsConditions under which the plan will be activatedExpense support of plan and impact on budgetProcedures for activating the planSequence of actions to be takenProcedures and resources for managing requestsMethods and schedules for updating the plan, communicating changes to staff, and training s

ComponentCompleted(date) 

ComponentUpdated(date) 

Functional Annex: The Continuity of Operations (COOP) PlanEssential functions and essential staff positionsContinuity of leadership and orders of successionLeadership for incident responseAlternate facilities (including the address of and directions/mileage to each) 

90 
91 

Worksheet B1 (page 2) 

ComponentCompleted(date) 

ComponentUpdated(date) 

Functional Annex: The COOP Plan (continued)Memoranda of Agreement (MOA) and qualified service organization agreements (QSOAs)Interoperable communicationsVital records and databases (backups and form of information)Management of human capitalStaff training planTesting and revisions of plan

ComponentCompleted(date) 

ComponentUpdated(date) 

Other Functional AnnexesList the annex for each essential activity that requires procedural instructions.

ComponentCompleted(date) 

ComponentUpdated(date) 

Hazard-Specific AppendicesList the appendix for each hazard identified by the hazard identification and risk assessmas most likely to occur and for which specific response guidance is necessary. 

ComponentCompleted(date) 

ComponentUpdated(date) 

Implementing InstructionsList the materials necessary to perform essential tasks in emergency.Safety policies and proceduresJob aids (checklists, worksheets, laminated wallet cards or sheets, scripts that staff can use whrelated information to clients and the public)Communication tree listing (home, work, and cell phone numbers; email addresses)Contact information for essential groups (see Worksheet B3)MOA and QSOAsBuilding addresses, phone numbers, floor plans, and building evacuation routesCommunity mapsOther: 
Worksheet B2 Checklist for Disaster Planning Name Date Instructions: Use with Chapter 2, Beginning the Disaster Planning Process. Indicate by date when each planning step has b

Date Addressed Planning Step Disaster planning team leader has been selected. Disaster planning team members provide representation for all departments, including: • Safety/security • Clinical management/services • Medication management/services • Counseling and case management services • Public relations (handling communications with client families, the media, the recovery community, and th

• Staff training and orientation • Compliance (privacy and regulatory knowledge) • Operations management • Engineering maintenance • Housekeeping services • Food services • Pharmacy services • Transportation services• Purchasing agent and contracts management• Medical records• Computer hardware and software system• Human resources• Billing• Corporate compliance (e.g., human rights, privacy, regulatory compliance)• Grant writing• Other members as appropriate (e.g., department heads; resident and family representatives; representat

cultures, languages, special interest groups; those with special emergency expertise, such as paramedic t

The organization’s leadership provides support to the team.The team has reviewed requirements for disaster planning.The team has coordinated with others in the State and community (see Worksheets B3 and B4).A hazard identification and risk assessment (HIRA) has been prepared.Planning objectives and assumptions have been specified; objectives are measurable and have been approOther: 

92 
93 

Worksheet B3 Checklist of State and Community Representatives and GroupsName Date Instructions: Use with Chapter 2, Beginning the Disaster Planning Process. Indicate by date when networking for disaster reestablished with each listed representative or group. Provide names, titles, and contact information. If multiple parties are invnetworking, attach a sheet listing all of them.

DateAddressed State/Community Representative/Group Names, Titles, and Contact Information (ph

State disaster behavioral health coordinatorOther behavioral health treatment programs in the communityPublic health departmentEmergency response organizationsLocal office of the Drug Enforcement Administration (DEA)State Opioid Treatment Authority (SOTA)Organizations of Pre-Credentialed Volunteers such as Citizen Corps Council (CCC) or Medical Reserve Corps (MRC)Voluntary organizationsVendors and other nearby businessesMedia contact and Public Information Officer of Incident Command System (ICS)Other: 
Worksheet B4 Checklist of Disaster Planning Discussion Topics Name Date Instructions: Use with Chapter 2, Beginning the Disaster Planning Process. Indicate by date when each action item has beeState disaster behavioral health coordinator (Part 1) and with public health department/local emergency planners (Part 2). Part 1: Action items to address with the State disaster behavioral health coordinator Date Addressed Action Item Obtain information on pertinent accreditation, licensing, or reimbursement requirements as well as regulat

governing disaster planning as it relates to behavioral health treatment programs. Become informed regarding State and local disaster planning contacts and the established network of orgadisaster planning at the local level. Obtain access to, and provide input on, the State disaster plan for behavioral health treatment programs. Learn about procedures for obtaining State, Federal, and private-sector assistance (including financial assispreparedness, disaster recovery, and expansion of services to respond after a disaster. Learn about assistance that can be obtained via the State from the U.S. Public Health Service CommissioneEmergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP), and volunteer gLearn about education, training, and support opportunities, including opportunities for staff members to leemergency preparedness. Develop ways to coordinate disaster planning with that of other behavioral health treatment programs in thObtain information about alternate sites that can provide behavioral health services in a disaster and the prreciprocal Memoranda of Agreement (MOA) or qualified service organization agreements (QSOAs) with theBecome informed of opportunities for trained staff to participate in the State and local disaster response dwithin the scope of providing appropriate services (e.g., psychological first aid and crisis intervention).Discuss the unique opportunities and capabilities of the program to assist its community in a time of disastneed from the State in a disaster, and the special services it can provide after a disaster.Other: 

94 
95 

Worksheet B4 (page 2)Part 2: Action items to address with the public health department/local emergency planners

Date Addressed Action Item

Obtain access to the community’s emergency operations plan.Learn whether behavioral health treatment programs’ capabilities are included in the community’s emergenand, if not, request their inclusion as an annex under Emergency Support Function (ESF) #8.Educate local emergency leadership about the program’s services, its importance to the community, the asand the local recovery community can provide in a disaster, and special needs the program and its clients mCoordinate with emergency responders on notification procedures in a disaster incident.Learn about education and training opportunities for the disaster planning team and/or for program staff (eCorps Councils).Learn about potential hazards that are particular to the community served by the program (i.e., obtain a hazrisk assessment [HIRA] from the Local Emergency Planning Committee).Learn about the Emergency Management Assistance Compact (EMAC) and how this might affect behavioraprograms.Consider and plan how all this information will be shared with leadership, the disaster planning team, and oappropriate.Other: 
Worksheet B5 Sheltering-in-Place Checklist Name Date Instructions: Use with Chapter 3, Preparing for Disaster. In column 1, indicate when the preparation listed in column 2 has bupdated. Date(s) Addressed/ Updated Preparation for Sheltering-in-Place Shelter space has been identified that offers maximum protection for the particular hazards deemed mo

the hazard identification and risk assessment (HIRA). Multiple spaces may be required for facilities locatefloor of a building or occupied by a large number of persons. Sheltering space may be different for diffeEmergency supplies have been stockpiled in the shelter areas within the site, preferably in movable contwheeled plastic storage bins. The quantity of supplies is based on the maximum number of people onsitplan is in place to rotate or discard and restock any perishables or supplies that expire, such as batteries accurate inventory of these supplies is kept current. The shelter space provides for communications (such as having a landline phone), sanitation, the needs omobility impaired or have special requirements, and pets, if any are routinely on premises. The shelter plan is coordinated with other tenants of the building. A chain of authority is established for communicating the need to shelter-in-place and indicating the all-Orders to shelter-in-place will be issued through several channels so that everyone onsite is reached, incvisually or hearing impaired or who do not speak English as their primary language. Members of the locaand special language groups have been consulted to determine the most effective strategies for notificaFor each shelter space, one or more staff persons should be assigned presheltering tasks, such as (if time • Shutting down critical operations including the ventilation system if advised given the emergency. • Transporting the facility go kit and an emergency supply of medications.• Locking doors.• Sealing the room as needed for the specific hazards (e.g., a biohazard incident) that warrant sealed roo• Taking a head count (using a prepared roster) of those sheltering.• Assisting sheltering persons in contacting family or others to inform about their location.• Arranging for personal comfort during confinement (e.g., coordinating sleeping arrangements).• Maintaining contact with emergency authorities.• Monitoring communications for official instructions.Multiple means are in place for alerting local authorities when sheltering-in-place so that they can assist deteriorates or there is a medical emergency.Staff and clients have been apprised of and drilled in sheltering plans to enhance willingness and coopeshelter-in-place is issued. People cannot be forced to shelter-in-place except by government emergency 

96 
97 

Worksheet B6 Record of Memoranda of Agreement and Qualified Service Organization Name DateInstructions: Use with Chapter 3, Preparing for Disaster. In the left column, list the agreements that have been negotiated. indicate the organization involved (if a multiparty agreement has been made, attach a sheet listing all parties), where the writstored, its expiration date, and special notes (e.g., costs, limitations).

Agreement Organization Name, Address, and Contact Information Location of Agreement Expiration Date Notes 
Worksheet B7 Incident Command System Positions Name Date Instructions: Use with Chapter 3, Preparing for Disaster. Complete at least the top table. For each position, list the primary or more backups. Worksheet B10 can be used to create a roster for the Incident Command System (ICS) positions. Position Incident Commander Liaison Officer Safety Officer Public Information Officer Agency Executive Primary Backup Backup Backu

Position Operations Team Leader Planning/Intelligence Team Leader Logistics Team Leader Finance/Administration Team Leader Primary Backup Backup Backu

98 
Worksheet B8 Identify Essential Functions

Name Date Instructions: Use with Chapter 4, Continuity Planning. Complete a copy of this worksheet for each department. List all functdepartment performs.

Department:Function 

Provides vital services toclients: Check(√) if yes 

Is required byregulation or law: Check (√)if yes 

Is required to maintainsafety forclients andstaff: Check (√) if yes 

Is a supportfunctionfor otheressentialfunctions:Check (√) ifyes 

Is essential for other reasons:If yes, explain below 

99 
100


 

Worksheet B9 Identify Essential Staff PositionsName Date Instructions: Use with Chapter 4, Continuity Planning. Complete a copy of this worksheet for each department. In the left codepartment’s essential functions (those determined to be essential on Worksheet B8) in priority order. In the right column, ideposition(s) necessary to perform the function.

Department:Essential Function Essential Staff Position (Note: There may be more than one.) 
Worksheet B10 Essential Staff Roster

Name Date Instructions: Use with Chapter 4, Continuity Planning. Complete a copy of this worksheet for each essential staff position ideB9. Record contact information for the primary staff member and backups who can perform the essential staff position’s dutie

Essential Staff Position:Information NameOffice phoneOffice emailAlternate emailCell phoneHome phonePhone contact outside city* 

Notes† 

Primary Staff Member Backup Backup Back

*Each staff member should provide emergency contact information, using a phone number (e.g., a friend’s or relative’s number) that is in a location distant fr

situations in which local communications systems are not working).

†Add any information pertaining to the staff member’s availability and scheduling preferences in emergency. 

101 
Worksheet B11 Checklist for Continuity Planning Name Date Instructions: Use with Chapter 4, Continuity Planning. Indicate by date when each planning question has been addressed or All Program Types Date(s) Addressed/ Updated Planning Question What is the approximate number of active clients participating onsite in services at various times of day

Do client medical/service records have current contact information? Have clients been requested to designate an emergency contact and signed a release of information alspecific information in case of an emergency? How can intake procedures be expedited in a time of disaster? Have procedures been written to suppostaff been informed of these modified procedures? At what times of the day are family members onsite, and how many are onsite at any one time? What lofamily members visit or congregate in? What type of documents will be accepted to establish client identity, especially for guest clients (e.g., dmilitary ID, other picture ID)? How will essential staff members be notified of the situation and their need to report for duty? How will treatment records be maintained and accessed during a disaster? If primary avenues for record inaccessible, what is the backup plan? How will client direct fees be determined and collected? How will billing be conducted (e.g., Medicaid, How can crisis/relapse prevention counseling be provided? Are crisis phone lines available in the prograrequest assistance from/referral to an existing hotline?How will crisis/relapse prevention counseling be provided? How will the availability of this resource be cclients?How will patients be assisted in accessing refills or replacements of prescribed or dispensed medicationWhich mutual-help groups will be available during or after a disaster? How can the program facilitate clgroups as needed in disaster?Is participation by staff in behavioral health response (e.g., crisis counseling teams) mandated? If yes, homay be called offsite, what credentials and training are required for those staff members, and how will tof staff members called offsite be covered?How will care be provided to clients as they are relocated or transferred?How will a system be implemented to reintegrate clients once the program resumes normal operations Other: 

102 
Worksheet B11 (page 2)

Outpatient Treatment Programs 

Date(s) Addressed/Updated Planning Question

In a disaster situation, how will client needs be prioritized (those who are at substantial risk of substance psychiatric illness if treatment is discontinued, those who can tolerate interruption of treatment)?Which clients are mandated for drug testing? How will drug testing for those clients be conducted undeconditions? Are there existing Memoranda of Agreement (MOA) that will provide alternate and secured who cannot travel to the facility for this service? If yes, how will this information be communicated to clieAre the program’s doctors prescribing medications to any patients? How will patients who need refills obackup options/agreements have been established for medication refills if the program’s doctors are noCan some clients be supported by telephone- or Web-based counseling? Have specific releases of infodeveloped and put in place to support getting client authorization for Web-based counseling? Have ththeir risks and benefits, been discussed with clients? What needs to be done to provide offsite support What arrangements need to be made to ensure that clients have access to counselors in shelters or othWhat contracts or MOAs are in place to bring in additional medical assistance through professional stafpersonnel shortage?Have staff members discussed with clients what changes might occur during an emergency situation anhow they would access services? Have clients been encouraged and directed to information that would disaster?Other:

Residential Treatment Programs 

Date(s) Addressed/Updated Planning Question

In a disaster situation, which staff members will be responsible for determining status of patients (those residential treatment, those who can be transferred or referred for treatment elsewhere, and those who How will parents/guardians of patients who are younger than 18 be notified of discharge or transfer plathan 18, how will family members or others involved with the patient’s care be notified?How will emergency condition discharges be handled in terms of providing patients with take-home mefor continuing care, and referral to outpatient treatment or mutual-help groups after the disaster has pawritten or transfer instructions related to this type of discharge and follow-up been provided to the patiHas a list been developed of emergency housing and shelters that will be available in the community fobe safely discharged in a disaster if they have someplace safe to go? Does this list include contact inforresources? How will this list be updated?Other: 

103 
Worksheet B11 (page 3) Medical Detoxification Date(s) Addressed/ Updated Planning Question In a disaster situation, how will patient status be determined (those who require continuing medical care

transferred or referred for treatment elsewhere, and those who can be discharged)? How can a specific treatment protocol of patients being detoxified be addressed and continued under erelated conditions? How can the specific needs of persons with physical or medical conditions that affect mobility or stability managed under emergency/disaster-related conditions? How will parents/guardians of patients younger than 18 be notified of discharge or transfer plans? For pahow will family members or others involved with the patient’s care be notified? How will emergency condition discharges be handled in terms of providing patients with take-home medfor continuing care, and referral to outpatient treatment or mutual-help groups after the disaster has pasWhat facilities can take patients needing continuing medical care? How will those patients be transportepatients’ medical information be transferred? How can assessment and intake be streamlined for intake during emergency conditions? Other: Opioid Treatment Programs (Note: See also Chapter 5, Management of Prescription Medications.) Date(s) Addressed/ Updated Planning Question How many of the program’s current patients will likely need methadone dosing within 24 hours of a disasHow many patients will need refills of their take-home methadone doses and within what timeframe?How much methadone will be needed onsite at any one time to provide take-home doses for all eligible emergency?How will dose information be accessed and maintained under emergency/disaster conditions?How will methadone be transported to patients at other locations (e.g., jails)? Who will be responsible foHow will patients who are disabled or affected by communicable disease, such as influenza, be provided In emergencies for which there is advance warning, can take-home doses of methadone be provided abquantities? If so, in what amounts? Can take-home privileges be extended to additional patients? If so, wHow will lockboxes be provided, as required, to patients provided with new take-home privileges? Has tthese changes been documented fully?How will exception requests (per Section 8.12 of 42 Code of Federal Regulations [CFR]) be submitted unscenarios to the Substance Abuse and Mental Health Services Administration (SAMHSA) and the State OAuthority (SOTA)?Other: 

104 
Worksheet B11 (page 4)

Primary Prevention Services (Note: Primary prevention will not be an essential service in a disaster.)

Date(s) Addressed/Updated Planning Question

How will participants of nonessential services be notified of the cancellation of these services?How will participants/clients be notified when regular services will be resumed? 

105 
106


 

Worksheet B12 Requirements for Alternate FacilitiesName Date Instructions: Use with Chapter 4, Continuity Planning. In the left column, list the behavioral health treatment program’s esse(from Worksheet B8). In the middle columns, estimate the number of people involved in each essential function at any one timrequirements to accommodate that number of people. Then, make a copy of this partly completed worksheet for every alterevaluated. On each copy, write the prospective alternate facility’s name and contact information and indicate whether it meeUse the data collected to compare prospective alternate facilities and to consider how to meet requirements that an alternatprovide. 

Alternate Facility Name, Address, and Contact Information:Essential Function 

Number ofStaff Members To Perform Function 

MaximumNumber ofClients Servedat any One Time 

Requirements: Estimate of needed floor space, furniture, beds (for male and female adults, adolescents, children), power, privacommunications, security, storage, restrooms, meal preparation serving areas, accessibility 
Worksheet B13 Alternate Facility Arrangements by Disaster Scenario

Name Date Instructions: Use with Chapter 4, Continuity Planning. For each disaster scenario, list the alternate facilities that have been a(e.g., whether prearrangements have been confirmed, costs for use, distance from facility, whether some staff members will wprogram has multiple sites, a separate sheet should be completed for each noting the specific alternate arrangements. Mem(MOA) and/or prearrangements are recommended for external sites not owned by the program. 

Disaster Scenario Primary Alternate Facility: Name, Address, Contact Information, and Notes Secondary Alternate Facility: Name, Address, Contact Infor

Internal (only the behavioral health treatment program site is affected)Local (the program site and its community are affected)Regional or national (the emergency affects a broad geographical area) 

107 
Worksheet B14 Checklist for Relocation Planning Name Date Instructions: Use with Chapter 4, Continuity Planning. Indicate by date when each planning step has been addressed or upd

Date(s) Addressed/ Updated Planning Step Options for relocation of operations have been identified and confirmed through Memoranda of Agree

Written agreements have been made with transport companies that will be used, such as bus and van sclients and staff. A plan for triaging patients has been detailed (to identify those who are able to be discharged and relothose who need further treatment or sheltering). Multiple routes to each predetermined alternate site have been mapped. Routes have been marked on with the emergency supplies or in facility vehicles. Disaster preparedness education and assistance, tailored to clients, have been provided. Vehicles that will be used in emergency evacuation are kept in ready condition and fully fueled. Drivers driver’s license for the vehicle and will have access to a credit card or cash in a disaster situation to pay fPrimary and backup transportation options have been identified. Modes of transportation will accommomoved who need special assistance (e.g., vans equipped for wheelchairs). The transportation plan consmove supplies including medications, computers, and so forth. A chain of authority is established for ordering full-site relocation and indicating the all-clear (in coordinemergency authorities) to return to the facility. One or more staff members have been assigned closing and relocation tasks, such as (if time permits):• Shutting down critical operations, including shutoff of utilities (e.g., gas or propane at main switches o

disconnection of electric appliances, extinguishing woodstove fires).

• Transporting the emergency supplies.• Transporting the facility go kit and emergency supply of medications.• Transporting other critical equipment such as hard drives or servers.• Locking doors and securing the building.• Supervising logistics of transporting people and supplies.• Taking a head count (using a prepared roster) of those relocating, and informing emergency authoriti

relocating or any missing persons and their likeliest locations.

• Coordinating with those in authority at the alternate site.• Informing emergency authorities of the facility’s evacuation plan. (Confidentiality regulations may rest

providing authorities with the names of clients who were relocated.)

• Locking cabinets and safes that contain controlled substances and medical equipment, or arranging f

secure transfer.

Procedures are in place to inform the public of the facility’s evacuation and the location of the alternate signs on door, message on telephone answering machine, information posted to Web site and social m

108 
Worksheet B15 Checklist for Maintaining Communications With Essential Groups

Name Date Instructions: Use with Chapter 4, Continuity Planning. For each essential group listed in the left column, place an X to indicacommunications will be maintained during an emergency.

Group 

Emergency respondersEssential staffNonessentialstaffClientsClient familiesSubstanceAbuse andMental HealthServicesAdministration(SAMHSA)Drug Enforcement Administration(DEA)Vendors/ insurersProviders of mutual aid 

LandlinePhone 

CellPhone/Smartphone 

Web Site orIntranet 

2-Way RadioorWalkieTalkie 

SatellitePhone 

Hotline(outsidefacility) 

GETS,WPS, orPriorityListing forElectricService* 

*GETS = Government Emergency Telecommunications Service; WPS = Wireless Priority Service 

AmateurRadio 

RecordedMessage 

SignonDoor

InPerson

109 
GETS, 2-Way WPS, or Cell Web Radio Hotline Priority Landline Phone/ Satellite Site or or (outside Listing Phone Smart- Phone Intranet Walkie- facility) for phone Talkie Electric Service* 

Sign 

Amateur Recorded In- on Radio Message Person Door 

Worksheet B15 (page 2)
 Group Referral agencies (e.g., service agencies that can assist with other emergency needs) Recovery advocates and groups State disaster behavioral health coordinator State Opioid Treatment Authority

(SOTA)LicensingEntityFundersor billingentities (e.g.,Medicaid)MediaOthers: 

*GETS = Government Emergency Telecommunications Service; WPS = Wireless Priority Service 

110 
111 

Worksheet B16 Checklist of Records and Databases To Ensure Interoperable CommunicName Date Instructions: Use with Chapter 4, Continuity Planning. For each category of record or database listed in the left column, placthe options for retrieving or entering data. Also indicate the staff members who have authority to retrieve or enter data and waccess to the passwords or authentication procedures for accessing the record.

Category ofRecord or Database Current clientmedicationinformationOther clientmedicalinformationClientpsychosocialhistoryClient billing informationDrug testingdataPersonnelinformationPayrollComputersystems information(networkdiagram,passwords)Vendor recordsOther: 

OnsiteComputer 

Offsite Server 

Laptop(batteryoperated)

PortableMemory Device(e.g., encrypted flash drive,encrypted DVD) 

Paper

Copies inFacilityGo Kit 

Other 

Staff Members With AuthEnter Information and WPasswords or AuthenticatAccessing the Record or 
Worksheet B17 Checklist for Protecting Records and Databases Name Date Instructions: Use with Chapter 4, Continuity Planning. For each category of record or database listed in the left column, prorequested in the other columns. Use this information to determine the steps to ensure protection of vital records and databa

Category of Record or Database Client clinical information Client billing information Legal and financial records (e.g., personnel, Social Security) Drug testing data Personnel contact information Essential staff credentials and State licenses Payroll Computer systems requirements (e.g., network diagram, passwords, and keys; equipment manufacturer, model, and serial numbers; installationprocedures and licenses)Software and hardware operation manualsOrder of succession, delegation of authority, and Incident Command System(ICS) structureOther: 

Form of Records/Databases andLocation 

Supporting Hardware/ Software Needed Frequency of Maintenance and Backup Backup Protections Means o

Records/

112 
Worksheet B18 Checklist for Managing Human Capital

Name Date Instructions: Use with Chapter 4, Continuity Planning. Indicate by date when each staff policy has been addressed or update

Date(s) Addressed/Updated Maintaining Contact With Staff

A system has been developed for staff members to contact supervisors following a disaster to inform the status, location, and current contact information.A system has been developed for the program to inform staff members of their work status (essential or whether they are to report for work or to stay home.

Date(s) Addressed/Updated Work Schedules

Staff members have been preassessed for their capacity during an emergency (e.g., availability to work oas needed, to assume other or additional duties, to deploy to an alternate facility).Staff functions that can be performed from home have been determined.Methods of tracking and supporting staff members reassigned to work at an alternate facility have been Staff members have been assisted in preplanning alternate means and routes of transportation to and fr

Date(s) Addressed/Updated Compensation and Leave

Pay rates for disaster situations have been determined (e.g., when staff members take on additional duticurrent level, duties at alternate facilities, work overtime, or stay overnight at the facility).A continuation plan has been determined for wages and salaries of employees who are unable to return following a disaster.A plan for payment of salaries in disaster situations has been determined (e.g., a backup system is in pladirect deposit is not available for payroll).Policies have been determined regarding whether staff members can take paid or administrative leave to volunteer in the community recovery after a disaster. 

113 
Worksheet B18 (page 2)
 Date(s) Addressed/ Updated Staffing Accommodations (e.g., day care) are available for essential staff members who have dependents and mi

after business hours or when schools/day care facilities are closed. Substitutes to fill essential positions have been identified from within the staff. Outside substitutes have been arranged with another behavioral health treatment program under the teagreement. An alternate plan is in place to fill essential positions, such as by using a placement firm or by developing temporary workers or volunteers (e.g., recent retirees). A procedure is in place for checking the credentials and conducting background criminal checks if necesproviders or volunteers brought on board immediately after a disaster. Date(s) Addressed/ Updated Training Staff members have been assigned for training or credentialing in disaster response (e.g., National IncidSystem [NIMS], Incident Command System [ICS]). Staff members have been assigned for training in trauma-informed therapy (e.g., CPR, first aid, psycholobereavement counseling). Staff members have been provided training to be culturally responsive to new populations that may seek disaster (e.g., people migrating from adjacent States or who have substance use disorders different from by the program). Staff members who may be assigned to alternate facilities through a mutual aid agreement have been crapproved for that work.Staff members have been selected and trained for participation on a behavioral health response team thcommunity.Staff members who may be offered for mutual aid have been trained and credentialed for that work.Staff members have been encouraged to develop home disaster plans.

Date(s) Addressed/Updated Staff Behavioral Health Needs

Staff members are trained to recognize the support needs of their colleagues and themselves during emrecovery phases.Employment policies address leave for staff to access services for dealing with disaster-related behavioraA list has been compiled of referral resources for staff members needing social services after a disaster (estress debriefing; disaster recovery assistance with housing, insurance claims, workers’ compensation).Policies are in place to support confidential self-referral or supervisor referral of staff members who are efor services to address stress and other reactions to disaster. 

114 
Worksheet B19 Checklist for Management of Prescribed Medications


115
 

Name Date Instructions: Use with Chapter 5, Management of Prescription Medications. Indicate by date when each planning step has updated.

Date(s) Addressed/Updated Planning Steps—All Programs

Clients have been advised on how to obtain prescription replacements and refills under various disaster Clients have been educated on what to carry with them when evacuating or seeking services at an alterncan obtain prescription replacement, refills, or methadone dosing.The program has communicated with the public health department for information on the public stockpThe topic of medication maintenance for clients has been addressed with local disaster planning commiPlans are in place for transfer and tracking of patients receiving medications to an alternate location or to be able to provide guest dosing or other prescription medications.Other: 

Date(s) Addressed/Updated Planning Steps—Opioid Treatment Programs

Patient medical records (including dose levels and take-home privileges) are stored and regularly update(e.g., an offsite server).The opioid treatment program (OTP) is ready to quickly and securely transfer patient records and the supalternate facility.The OTP is ready to submit exception requests to the Substance Abuse and Mental Health Services Admand the State Opioid Treatment Authority (SOTA) (as authorized).The option of providing patients with smart ID cards has been considered. If smart ID cards are used, othidentified that have the equipment to read the cards and that can accept guest patients in emergency. A transferring medical data has been established, in case patients lose their smart ID cards.The program has discussed with its SOTA the capabilities of its central database and has determined the accessing patient records in emergencies. Issues covered include:• How patient information will be accessed when records at the program are destroyed or inaccessible.• How information on guest patients from other OTPs will be accessed.• How the OTP’s patient records will be accessed by other OTPs providing guest dosing.• Whether patient releases and other permissions will be required to access patient records.• Whether dosage information from guest patients will be relied on before verification of that informatio

patients’ home OTPs.

The program is aware of the current status of State-run healthcare communications systems through whican be securely transferred.Procedures are in place for handling patients who request courtesy dosing after a disaster and/or for refeguest patients elsewhere when the facility does not have the resources to handle those guest patients its
Worksheet B19 (page 2)
 Date(s) Addressed/ Updated Planning Steps—Opioid Treatment Programs (continued) Procedures are in place for handling an influx of new patients after a disaster. Procedures are in place for referring prospective pain patients to providers who can assist with pain man

Program staff is aware of lawful procedures for moving controlled substances and the procedures for reqThe Drug Enforcement Administration (DEA) agent for the program’s jurisdiction has been informed abomaintenance treatment and use of other controlled substances for behavioral health treatment and aboufor expedited permissions in emergencies. The local law enforcement agency has been advised that controlled substances are located on the properequested to provide the facility with high-priority protection if looting occurs following a disaster or with transporting program supplies to an alternate facility. Contingency plans have been developed for resupply of methadone if the original supply becomes destCounselors have discussed with physicians and pharmacies the options patients have to obtain prescriptrefills under various scenarios (e.g., if patients cannot contact their prescribing physician, if their primary they are relocated). Counselors and/or OTP physicians provide education to patients on what to do to maintain supplies of tOther: 

116
 
117 

Worksheet B20 Disaster Plan Training and Testing LogName Date Instructions: Use with Chapter 7, Completing, Testing, Activating, and Deactivating the Plan. List each training and testing column and details about that activity in the other columns.

Training/Testing Activity Date Conducted Objective Sponsor/Provider (note credentials) Department/Group

Participating 

 

CCC 

Appendix C—Abbreviations and Acronyms
 

AFC	 Access Family Care 

Citizen Corps Council 

CCP	 Crisis Counseling Assistance and Training Program 

CDC	 Centers for Disease Control and Prevention 

CFR	 Code of Federal Regulations 

COOP	 continuity of operations 

CSAT	 Center for Substance Abuse Treatment 

DATA	 Drug Addiction Treatment Act 

DCM	 Disaster Case Management (Federal program) 

DEA	 U.S. Drug Enforcement Administration 

DHS	 U.S. Department of Homeland Security 

DPT	 Division of Pharmacologic Therapies 

DTAC	 Disaster Technical Assistance Center 

ED	 emergency department 

EHR	 electronic health record(s) 

EMAC	 Emergency Management Assistance Compact 

EMI	 Emergency Management Institute 

EMR	 electronic medical record(s) 

ESAR-VHP	 Emergency System for Advance Registration of Volunteer Health Professionals 

ESF	 Emergency Support Function 

FEMA	 Federal Emergency Management Agency 

GETS	 Government Emergency Telecommunications Service 

HHS	 U.S. Department of Health and Human Services 

HIPAA	 Health Insurance Portability and Accountability Act 

HIRA		 hazard identification and risk assessment 

119 
Disaster Planning Handbook for Behavioral Health Treatment Programs

120 

HIT health information technology 

ICS Incident Command System 

KAP Knowledge Application Program 

MMT methadone maintenance treatment 

MOA Memorandum of Agreement (singular); Memoranda of Agreement (plural) 

MOU Memorandum of Understanding (singular); Memoranda of Understanding (plural) 

MRC Medical Reserve Corps 

NDRF National Disaster Recovery Framework 

NGO nongovernmental organization 

NIMS National Incident Management System 

OTP opioid treatment program 

PAD psychiatric advance directive 

POD point of distribution 

PTSD posttraumatic stress disorder 

QSOA qualified service organization agreement 

SAAS State Associations of Addiction Services 

SAMHSA Substance Abuse and Mental Health Services Administration 

SBIRT screening, brief intervention, and referral to treatment 

SERG SAMHSA Emergency Response Grant 

SMA State Methadone Authority 

SOTA State Opioid Treatment Authority 

SSA Single State Agency 

TAP Technical Assistance Publication 

THIRA threat and hazard identification and risk assessment 

VOAD Voluntary Organization Active in Disaster 

WATrac Washington System for Tracking Resources, Alerts, and Communication 

WPS Wireless Priority Service 
121 

Appendix D—Disaster Planning Web 

Resources 

Resources From the Substance Abuse and Mental Health Services 

Administration (SAMHSA) 

After the Crisis Initiative: Healing from Trauma after Disasters (provides information on 

training people for peer support in and after disaster):

http://gainscenter.samhsa.gov/atc 

Behavioral Health Treatment Services Locator: 

http://findtreatment.samhsa.gov 

Disaster Technical Assistance Center (provides access to technical assistance, resources

on preparedness and response, and a contact database of State and territory disaster

behavioral health coordinators):

http://www.samhsa.gov/dtac 

Exception Requests (for the administration and management of opioid treatment):

http://www.dpt.samhsa.gov/regulations/exrequests.aspx 

Federal Opioid Guidelines, April 2013:

http://www.dpt.samhsa.gov/pdf/FederalGuidelinesforOpioidTreatment5-6­

2013revisiondraft_508.pdf 

Medication-Assisted Treatment: 

http://dpt.samhsa.gov 

Opioid Treatment Program Directory:

http://dpt2.samhsa.gov/treatment/directory.aspx 

SAMHSA’s Disaster Behavioral Health Information Series Resource Collections (contains

themed installments of resources and toolkits in disaster behavioral health. Each 

installment focuses on a specific population, disaster type, or other topic pertinent to

disaster behavioral health preparedness, response, and recovery):

http://www.samhsa.gov/dtac/dbhis 

State Opioid Treatment Authorities:

http://dpt2.samhsa.gov/regulations/smalist.aspx 
Disaster Planning Handbook for Behavioral Health Treatment Programs

At-Risk Populations and Disaster 

Health Information Translations: Quality Health Education Resources for Diverse Populations

(provides translations into multiple languages of disaster preparedness and response

information for clients), Ohio State University Medical Center, Mount Carmel Health System,

Ohio Health, and Nationwide Children’s Hospital:

https://www.healthinfotranslations.org/disaster-preparedness.php 

National Council on Disability:

http://www.ncd.gov 

National Resource Center on Psychiatric Advance Directives:

http://www.nrc-pad.org 

Psychosocial Issues for Older Adults in Disasters, SAMHSA and the National Council on Aging:

http://store.samhsa.gov/shin/content//SMA11-DISASTER/SMA11-DISASTER-03.pdf 

Special Populations: Emergency and Disaster Preparedness, National Library of Medicine,

National Institutes of Health: 

http://sis.nlm.nih.gov/outreach/specialpopulationsanddisasters.html 

Staying in Touch: A Fieldwork Manual of Tracking Procedures for Locating Substance Abusers 

in Follow-up Studies (2nd ed.), University of California, Los Angeles, Integrated Substance 

Abuse Programs (a model client locator form is located in Appendix A):

http://www.uclaisap.org/trackingmanual/manual/Tracking-Manual.pdf 

Tips for People With Disabilities and Medical Concerns, Independent Living Resource Center of

San Francisco: 

http://www.ilrcsf.org/wp-content/uploads/2012/09/Emergency-preparedness-for-people-withdisabilities.pdf 

Communications 

Government Emergency Telecommunications Service, U.S. Department of Homeland

Security (DHS):

http://www.dhs.gov/government-emergency-telecommunications-service-gets 

Wireless Priority Service, DHS:

https://www.dhs.gov/wireless-priority-service-wps 

Electronic Health Records 

Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs, Center for

Medicare & Medicaid Services (CMS):

https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html 

Office of the National Coordinator for Health Information Technology, U.S. Department of

Health and Human Services (HHS):

http://www.healthit.gov 

122 
Appendix D—Disaster Planning Web Resources 

Emergency Planning for Staff and Clients 

Basic Disaster Supplies Kit, Federal Emergency Management Agency (FEMA):

http://www.ready.gov/basic-disaster-supplies-kit 

National Preparedness Month, National Child Traumatic Stress Network 

(resources for families):

http://www.nctsn.org/resources/public-awareness/national-preparedness-month 

Plan & Prepare, American Red Cross:

http://www.redcross.org/prepare 

Ready.gov (consumer readiness Web site), FEMA:

http://www.ready.gov 

Red Cross Mobile Apps:

http://www.redcross.org//prepare/mobile-apps 

Federal Guidance and Support 

Business (readiness Web page), FEMA:

http://www.ready.gov/business 

Continuity of Operations, FEMA:

http://www.fema.gov/continuity-operations 

Emergency Authorization for Disaster Relief—Domestic and International, Office of Diversion

Control, Drug Enforcement Administration:

http://www.deadiversion.usdoj.gov/disaster_relief.htm 

Guidance on Planning for Integration of Functional Needs Support Services in General 

Population Shelters, FEMA: 

http://www.fema.gov/pdf/about/odic/fnss_guidance.pdf 

Homeland Security Exercise and Evaluation Program, DHS:

https://www.llis.dhs.gov/hseep 

Independent Study Program, FEMA (provides courses on topics including emergency

management, continuity of operations, and Federal guidance):

http://training.fema.gov/IS 

National Disaster Recovery Framework, FEMA: 

http://www.fema.gov/media-library-data/20130726-1820-25045-5325/508_ndrf.pdf

National Incident Management System, FEMA:

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

National Preparedness Goal (1st ed.), FEMA:

http://www.fema.gov/pdf/prepared/npg.pdf 

National Preparedness System, FEMA: 

http://www.fema.gov/pdf/prepared/nps_description.pdf 

123 
Disaster Planning Handbook for Behavioral Health Treatment Programs

124 

National Response Framework, FEMA:

http://www.fema.gov/national-response-framework 

Planning & Templates, FEMA:

http://www.fema.gov/planning-templates 

Survey & Certification—Emergency Preparedness, CMS (provides guidance for State Survey

Agencies and healthcare providers):

https://www.cms.gov/SurveyCertEmergPrep 

Financial Aid for Programs 

Crisis Counseling Assistance and Training Program (CCP), SAMHSA and FEMA:

http://store.samhsa.gov/shin/content//SMA11-DISASTER/SMA11-DISASTER-17.pdf 

Disaster Loans, Small Business Administration: 

http://www.sba.gov/category/navigation-structure/loans-grants/small-business-loans/

disaster-loans 

Robert T. Stafford Disaster Relief and Emergency Assistance Act, as Amended, 

and Related Authorities, FEMA: 

http://www.fema.gov/pdf/about/stafford_act.pdf 

Information for Medical and Health Professionals 

Emergency Management Assistance Compact:

http://www.emacweb.org 

NIDAMED (tools and resources that assist healthcare providers in identifying drug use early

and in referring patients to treatment):

http://www.drugabuse.gov/nidamed-medical-health-professionals 

Public Health Mutual Aid Agreements—A Menu of Suggested Provisions, Centers for Disease 

Control and Prevention (CDC):

http://www.cdc.gov/phlp/docs/Mutual_Aid_Provisions.pdf 

Sample Qualified Service Organization Agreement:

http://www.lac.org/doc_library/lac/publications/QSO-BA%20Agreement%20Form.pdf 

Screening, Brief Intervention, and Referral to Treatment (SBIRT), SAMHSA:

http://www.samhsa.gov/prevention/sbirt/ 
125 

Appendix D—Disaster Planning Web Resources 

Pandemic Planning 

Flu.gov—Know What To Do About the Flu, HHS:

http://www.flu.gov 

IS-520: Introduction to Continuity of Operations Planning for Pandemic Influenzas (interactive

online course), FEMA:

http://training.fema.gov/EMIWeb/IS/IS520.asp 

Seasonal Influenza (Flu), CDC:

http://www.cdc.gov/flu 

Planning 

Emergency Preparedness, Small Business Administration:

http://www.sba.gov/prepare 

Public Health Practices: Enhancing Emergency Preparedness and Response, Center for

Infectious Disease Research & Policy, University of Minnesota:

http://www.cidrap.umn.edu/public-health-practices 

Strengthening Emergency Response Through a Healthcare Coalition: A Toolkit for Local

Health Departments, Public Health—Seattle & King County:

http://www.apctoolkits.com/kingcountyhc/ 

Pre-Credentialed Volunteer Organizations 

Citizen Corps:

http://www.ready.gov/citizen-corps 

Emergency System for Advance Registration of Volunteer Health Professionals:

http://www.phe.gov/esarvhp/Pages/home.aspx 

Medical Reserve Corps:

http://www.medicalreservecorps.gov 

Voluntary Organizations 

American Red Cross: 

http://www.redcross.org 

National Voluntary Organizations Active in Disaster:

http://www.nvoad.org 

Appendix E—WATrac*
 

WATrac (Washington System for Tracking Resources, Alerts, and Communication) is a

web-based application serving the Washington healthcare system by providing two distinct

functions: 1) daily tracking of agency status and bed availability and, 2) incident management

and situational awareness during a disaster response. 

The system provides a means for notifying healthcare partners of emergency incidents and for

supplying situational updates throughout the event. During an incident the daily facility status

and bed tracking feature not only provides emergency medical services (EMS) and hospitals

with patient transport information, but also automates the process for obtaining bed counts

for statewide updates. Command Center, for on-line chat and conferencing, provides an easily

accessible tool for real-time communication within agencies and between healthcare partners. 

WATrac is web-based and will run on any computer with an internet connection, standard

web plug-ins, and Adobe Flash 10.0 or newer. The system meets HIPAA [Health Insurance

Portability and Accountability Act] security requirements by providing 128-bit encryption

for all transmitted data. Access to data is controlled by user permission groups, and strong

passwords can be required. The HIPAA requirement for recording who views, updates, or edits

records is met only by the Patient Tracking module. All other modules and features in WATrac 

are not HIPAA compliant. 

The WATrac application and data resides on servers in Minneapolis with back-up servers

containing duplicate data in Chicago. This service includes dynamic redirection in the event of

a server failure. 

The Washington State Department of Health and participating regions, support statewide

implementation using federal funds. WATrac is administered and maintained as a

partnership between the Washington State Department of Health and Public Health—Seattle

& King County. A statewide Advisory Group made up of representatives from healthcare,

EMS, and public health provides direction and input for future use and implementation of the

WATrac system. 

Full system access is currently available to hospitals, EMS, trial health, community health

centers, public health, nursing homes, and in-home service providers throughout Washington

State. Additional access is being guided by the WATrac Advisory Group and by resources and

staff availability. 

For More Information 

Email: support@watrac.org 

*

Excerpted from Washington State Department of Health and Public Health—Seattle & King County (2012). 

127 

Appendix F—Sample Memorandum of 

Agreement Between Opioid Treatment 

Programs* 

Note: This Memorandum of Agreement (MOA) is provided for example purposes only.

Programs should seek legal counsel before using or signing any legal document. 

Continuity of care for patients of licensed opioid treatment program (OTP)

providers in times of emergencies 

Between the following providers: 

__________________________________________ (Licensed OTP Provider) 

__________________________________________ (Licensed OTP Provider) 

__________________________________________ (Licensed OTP Provider) 

__________________________________________ (Licensed OTP Provider) 

[add more lines as needed] 

1 . Purpose 

Each signing party of this MOA desires to voluntarily aid and assist one another by the

interchange of resources and services if an emergency or disaster should occur in which

a signing party cannot provide opioid replacement medication to all or a portion of its

patients. The signing parties agree that this MOA, however, will not create a legal duty to

provide assistance. 

This memorandum defines the responsibilities of the parties and establishes a mechanism

whereby a licensed OTP provider (receiving provider) dispenses methadone or other

prescribed opioid replacement medication during an emergency on behalf of the OTP

provider in which the patient is enrolled (primary provider).
 

2 . Description 

Licensed OTP providers enter into this MOA to provide prescribed opioid replacement

medication to enrolled patients in an emergency in which either provider cannot serve its

patients. Emergency circumstances include loss of power, structural damage to facility, fire,

flooding, or staff shortage. 

*Adapted from an unpublished document provided courtesy of King County (WA) Healthcare Coalition. 

129 
Disaster Planning Handbook for Behavioral Health Treatment Programs

130 

The following are the minimum tasks that will be performed by the receiving provider when

the MOA is activated: 

a. Provide short-term (30 or fewer consecutive days) methadone dosing of primary

provider’s patients. 

b. For receiving providers who are licensed to dispense opioid replacement medication in

addition to methadone (e.g., buprenorphine), provide short-term (30 or fewer consecutive 

days) dosing of prescribed opioid replacement medication to primary provider’s patients. 

c. Document dispensing and treatment in accordance with county, State, and Federal

requirements. 

d. Make best effort to verify patient’s dosage. 

e. Make best effort to verify patient’s identity. 

f. Within 90 days, communicate to primary provider information that is required (e.g.,

activity information, discharge data) for the State registry of OTP patients (if such

registry exists) and for State billing purposes. 

g. Communicate to primary provider clinically significant information (e.g., recent history

of missed dosage, impairment, pregnancy, medication changes). 

h. Dispense up to 30 mg of methadone to patient if verification of dosage is not reasonably

possible after best efforts to do so have been made. 

i. Keep records of dispensing, including doses delivered and by whom, and submit them to

primary provider within 15 calendar days after services are rendered. 

j. If operational, use [name of system being used to securely exchange information] to

assist with sharing patient data (e.g., identity and dosage verification) and clinically

significant information. 

The following are the minimum tasks that will be performed by the primary provider when

the MOA is activated: 

a.	 Make best effort to give receiving provider patient names, name of opioid replacement

medication prescribed, amount and date of last dosage, any other clinically significant

information, and additional information that will assist in verifying patient identity

(e.g., race/ethnicity, date of birth, last four digits of Social Security number). 

b.	 Input required data into State registry of OTP patients if such registry exists. 

c.	 Bill State of [name of State] or other funding source for services rendered to primary

provider’s patients by receiving provider while this MOA is activated. 

d.	 Communicate to patients where to present for dosage and which documents and items

to bring (e.g., picture ID, pill bottle, prescription). 
131 

Appendix F—Sample Memorandum of Agreement Between Opioid Treatment Programs 

e. Deploy clinical or administrative staff from the primary agency to the receiving agency

when requested by the receiving provider for activities such as dispensing, counseling,

and other medical care. 

f. Make best efforts to transport opioid replacement medication and a completed Drug

Enforcement Administration Form 222 from primary provider’s supply to receiving 

agency. 

g. If operational, use [name of software being used to securely exchange information] to

assist with sharing patient data (e.g., identity and dosage verification) and clinically

significant information. 

3 . Activation and Deactivation 

This MOA shall become effective immediately on its execution by the signatory providers’

respective executive directors or designees. This MOA is activated by written or oral

notification by the primary provider’s executive director or his/her designee to the receiving

provider’s executive director or his/her designee and by written or oral communication by

the receiving provider of activation of the MOA. Activation of this MOA may occur at any

time, day or night, including weekends and holidays. 

Mutual aid shall continue to be available until participation in activation is terminated in

writing by the withdrawing parties. The receiving provider agrees to give reasonable notice

to the primary provider before withdrawing assistance. 

4 . Terms and Termination of MOA 

a.	 This MOA shall be in full force and effect from date of execution [date] through ending

date [date] but will be renewed automatically unless terminated pursuant to the terms

hereof. 

b.	 Signing parties may terminate this MOA with written notification to the other signing

parties no less than 30 calendar days in advance of the termination date. 

c.	 The receiving provider’s clinical personnel who care for primary provider’s patients

must be in good standing with the receiving provider and be current on all requisite

licensing and permitting. 

d.	 The receiving provider and its participating personnel must abide by all Federal, State,

and local laws. 

e.	 The primary and receiving providers must ensure that detailed records of expenditures

and time spent by deployed staff are complete and accurate and have adequate

supporting documentation. 

5 . Employees 

If the receiving provider requests clinical or administrative staff members from the primary

provider, employees of a primary provider shall at all times while providing assistance

continue to be employees of the primary provider. Wages, hours, and other terms and

conditions of employment of the primary provider shall remain applicable to all of its

employees who provide assistance under this MOA. The primary provider shall be solely 
Disaster Planning Handbook for Behavioral Health Treatment Programs

132 

responsible for payment of its employees’ wages, required payroll taxes, and benefits or

other compensation. The receiving provider shall not be responsible for paying wages,

benefits, taxes, or other compensation to the primary provider’s employees. 

Each party shall pay workers’ compensation benefits to its own injured personnel, if such

personnel sustain injuries or are killed while rendering aid under this MOA, in the same

manner and on the same terms as if the injury or death were sustained serving its own

patients. Nothing in this MOA shall abrogate or waive any party’s right to reimbursement

or other payment available from any local, State, or Federal government or abrogate or

waive the effect of any waiver, indemnity, or immunity available to a party under local,

State, or Federal law or other governmental action. To the extent that such reimbursement,

payment, waiver, indemnity, or immunity does not apply, then each party shall remain

fully responsible as employer for all taxes, assessments, fees, premiums, wages,

withholdings, workers’ compensation, and other direct and indirect compensation, benefits,

and related obligations with respect to its own employees. Each party shall provide workers’ 

compensation in compliance with the statutory requirements of the State of [name of State]. 

6 . Cost and Method for Reimbursement 

a.	 The receiving provider must submit to the primary provider complete and accurate

documentation of services rendered to patients of the primary provider, which include

dispensing records and an invoice, within 15 calendar days after rendering services. 

b.	 On receiving complete and accurate documentation from the receiving provider

and agreement of invoice, the primary provider will submit documentation for

reimbursement at the Medicaid rate at time of service to the State of [name of State] or

other funding source as applicable. 

c.	 The primary provider will reimburse the receiving provider within 15 calendar days of

receiving payment from the State of [name of State] or other funding source. 

d.	 If the primary provider has not reimbursed the receiving provider within 15 calendar

days, the receiving provider can allow a 45-day grace period to the primary provider.

At the end of the grace period, the receiving provider may take appropriate action to

pursue reimbursement. 

7 . Contract Claims 

This MOA shall be governed by and construed in accordance with the laws of the State of

[name of State] as interpreted by the State of [name of State] courts. However, the parties

may attempt to resolve any dispute arising under this MOA by any appropriate means of

dispute resolution. 

8 . Acceptance of Agreement 

Providers offering to enter into this MOA shall fully complete this MOA with the

information requested herein and sign two originals of a fully completed MOA. Each

provider will keep one of the original MOA.
 
133 

_____________________________________________
 

_____________________________________________
 

_____________________________________________
 

_____________________________________________
 

_____________________________________________
 

_____________________________________________
 

_____________________________________________
 

_____________________________________________
 

_____________________________________________
 

_____________________________________________ 

_____________________________________________ 

_____________________________________________ 

_____________________________________________ 

_____________________________________________ 

Appendix F—Sample Memorandum of Agreement Between Opioid Treatment Programs 

In addition, a copy of the MOA, signed and fully completed by the providers, shall be faxed 

or sent to: 

To: [Insert the name, address, and contact information including fax number for outside

party location, such as the Single State Agency for Substance Abuse.] 

As noted by the providers’ signatures (below), the providers agree to the terms

and conditions as set forth in this MOA and agree to abide by the requirements for

reimbursement. All amendments to this MOA must be in writing and agreed to by both

providers. 

OTP provider [Insert the following information for each party to the MOA]: 

Company Name 

Business Address 

Phone No. 

Fax No. 

Email Address 

After-hours emergency contact information:
 

Contact Name 

Phone No. 

Fax No. 

Cell No. 

Email Address 

Signature of Chief Executive 

Printed Name 

Title 

Date 

Appendix G—Editorial Board 


and Field Reviewers
 

Editorial Board 

Ron Jackson, M .S .W . 

Executive Director 

Evergreen Treatment Services

Seattle, Washington 

Elizabeth Ludeman-Hopkins, M.P.A., CAC

Performance Improvement Director

Central Virginia Community Services

Lynchburg, Virginia 

Jane Maxwell, Ph .D . 

Senior Research Scientist 

Addiction Research Institute 

University of Texas

Austin, Texas 

Michelle McDaniel, M .B .A ., M .H .P . 

Emergency Preparedness Planning Manager

Public Health—Seattle and King County

Seattle, Washington 

Deborah Podus, Ph .D . 

Associate Research Sociologist

Semel Institute for Neuroscience and Human 

Behavior 

UCLA Integrated Substance Abuse Programs

David Geffen School of Medicine at UCLA 

Los Angeles, California 

Field Reviewers 

Laura J. Copland, M.A., LCMHC (NH)

Director, Behavioral Health Disaster Services 

and Veterans Reintegration Issues

State of Maryland Department of Health and

Mental Hygiene

Jessup, Maryland 

Michael Duffy, RN, CD

Programing Consultant

Michael Duffy Consulting 

Little Elm, Texas 

Thomas R. Franz 

Assistant Director, Behavioral Health 

Disaster Services 

Mental Hygiene Administration

State of Maryland Department of Health and

Mental Hygiene

Jessup, Maryland 

Chance A . Freeman 

Branch Manager

Disaster Behavioral Health Coordinator 

Disaster Behavioral Health Services 

Mental Health and Substance Abuse Division 

Texas Department of State Health Services

Austin, Texas 

John Lowe, RN, Ph.D., FAAN 

Associate Professor 

Christine E. Lynn College of Nursing

Florida Atlantic University

Davie, Florida 

Michael Lynde

Program Director

New Freedom Center 

Bismarck, North Dakota 

Rodrigo Monterrey

All-Hazards Coordinator/Substance Abuse 

Disaster Coordinator 

Bureau of Substance Abuse Services 

Massachusetts Department of Public Health

Boston, Massachusetts 

Paul Nagy, M.S., LPC, LCAS, CCS

Director of Clinical Consultation and 

Training

Duke Addictions Program

Duke University Department of Psychiatry 

and Behavioral Sciences 

Duke University

Durham, North Carolina 

135 
136 

Disaster Planning Handbook for Behavioral Health Treatment Programs 

Amy B. Smith, LPC, MAC, NCC, SAP

Capital Counseling Services

Washington, District of Columbia 

Kathyleen M . Tomlin, M .S ., CADC III

Private Practice Consultant & Counseling 

Supervision

Cheyenne River Training and Consulting

Portland, Oregon 

Cynthia Moreno Tuohy, NCACII, 

CCDCIII, SAP 

Executive Director 

NAADAC, the Association for Addiction 

Professionals 

Alexandria, Virginia 

Katie Wells, M .P .A ., CAC III 

Manager, Adolescent Substance Use Disorder 

Programs

Division of Behavioral Health 

Denver, Colorado 

Ednita M. Wright, Ph.D., LCSW, CASAC

Associate Professor 

Human Services/Teacher Education 

Department

Onondaga Community College

Syracuse, New York 
Appendix H—Acknowledgments 

Numerous people contributed to the development of this Technical Assistance Publication

(TAP), including the Editorial Board and field reviewers (see Appendix G). 

This publication was produced under the Knowledge Application Program (KAP), a Joint

Venture of The CDM Group, Inc., and JBS International, Inc. (JBS), for the Substance Abuse

and Mental Health Services Administration, Center for Substance Abuse Treatment. 

Lynne MacArthur, M.A., A.M.L.S., served as the JBS KAP Executive Project Co-Director, and

Barbara Fink, RN, M.P.H., served as the JBS KAP Managing Project Co-Director. Other JBS

KAP personnel included Catherine Baker, M.Ed., Writer; Wendy Caron, Quality Assurance

Editor; and Suzanne Garber, M.A., Quality Assurance Editor. 

137 
Technical Assistance Publications (TAPs) include:

TAPs 1–18, 20, 23–27 are no longer available. 

TAP 19 Counselor’s Manual for Relapse Prevention With Chemically Dependent Criminal Offenders 

TAP 21 Addiction Counseling Competencies: The Knowledge, Skills, and Attitudes of Professional Practice 

TAP 21-A Competencies for Substance Abuse Treatment Clinical Supervisors 

TAP 22 Contracting for Managed Substance Abuse and Mental Health Services: A Guide for Public Purchasers 

TAP 28 The National Rural Alcohol and Drug Abuse Network Awards for Excellence 2004, Submitted and 

Award-Winning Papers 

TAP 29 Integrating State Administrative Records To Manage Substance Abuse Treatment System Performance 

TAP 30 Buprenorphine: A Guide for Nurses 

TAP 31 Implementing Change in Substance Abuse Treatment Programs 

TAP 32 Clinical Drug Testing in Primary Care 

TAP 33 Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment 

TAP 34 Disaster Planning Handbook for Behavioral Health Treatment Programs 

TAPs may be ordered or downloaded from SAMHSA’s Publications Ordering Web page at 

http://store.samhsa.gov. Or, please call SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727) (English and Español). 
HHS Publication No. (SMA) 13-4779

Substance Abuse and Mental Health Services 

Administration

Printed 2013