Dialysis: Insulin: Walker/cane/scooter/wheelchair: Ventilator: Oxygen: Other (please specify): Service animal: Bariatric Bed Other machine dependent: Table 1 Primary and Affiliate/Sister Facilities (See Attachment E) Primary Facility Facility Name Address (Street, City, State, Zip) County Contact Number Affiliate/Sister Facilities (Include specific information in Attachment E.) Facility Name Address (Street, City, State, Zip) County Contact Number Signature Page <Insert Facility Name>
vendors. A list containing the names and contact information of the vendors that deliver and/or manufacture supplies and provide critical services can be found in Annex A: Communications Plan. If the hospital is unable to acquire sufficient resources through outside vendors and arrangements to meet the healthcare needs of the community, the <Insert position title> will communicate this need to the <insert name of local emergency management agency> to help locate resources and replenishments. If sufficient supplies cannot be acquired, the local emergency management agency will also provide assistance coordinating the transfer of patients to other facilities upon request. B. Sharing Resources with Other Healthcare Organizations Include procedure for sharing or borrowing supplies within the hospital network, if applicable. If the healthcare organizations sharing the resources are within <Insert name of jurisdiction>, a Resource Accounting Record form (HICS Form 257) should be used to document the borrowed or loaned products. See sample HICS forms in Attachment D. The equipment should then be returned after use. Any consumable supplies that are used should be billed via invoice and paid by the organization using the supplies. Any unused consumables should be returned. Include other procedures, if applicable. If the items shared or borrowed come from outside <Insert name of jurisdiction>, the request should be coordinated through the <Insert name of emergency management agency>. The facility should document the final location of the supplies and the quantity and type of items transported. The need must be demonstrated to exceed that of the local jurisdiction prior to disbursement of supplies or equipment. Include other procedures, if applicable. C. Monitoring Quantities of Resources and Assets The <Insert position title> is responsible for monitoring quantities of assets and resources during an emergency. A Resource Accounting Record form (HICS Form 257) should be used when resources and assets are tracked during an emergency. See sample HICS forms in Attachment D. Available services and resources can also be tracked daily using the State Medical Asset Resource Tracking Tool (SMARTT) System. For additional information on the SMARTT System, see Annex E.
ABC Hospital* Alternate/Devolution Site 1234 Medical Center Drive, Niceville, MS Identified meeting rooms with telephones, internet access, ham radio access, satellite radio access, 2 desktop computers, laptop connectivity County EOC* Alternate/Devolution Site 7000 Disaster Way, My Town, Gotham City Possible meeting room with telephones, internet access, shared ham radio capability, shared satellite phone capability, no desktop computers, laptop connectivity Home Telework* Alternate/Devolution Site Home of Record Facility Leadership Telephones, internet access, no ham radio, no satellite phone, desktop computers, laptop connectivity *Examples Table 22 Alternative Care/Surge Site Locations Facility Name Admin Facility Emergency Care Acute Care beds available Low Acuity Skilled Nursing Care HCC Headquarters* St. Joseph’s Training Room N/A N/A N/A N/A Hospital A* Contracted Hot site Deployable Shelter Sister Facility Reopen Closed Wards Affiliated LTC Hospital B* No Admin Location Mobile Trailer No Acute Care Capability College Gymnasium No Long Term Capability Nursing Home* Affiliated System Affiliated System Affiliated System Affiliated System Affiliated System Dialysis Center* No Admin Location Closest ER Closest Hospital Closest Hospital Closest LTC *Examples Continuity Communications The <Insert name of facility> maintains a robust and effective communications system to provide connectivity to internal response players, key leadership, and state and