Patients in Care Provide the average number of individuals within the facility’s care who have the following disabilities and/or dependencies: Disability or Other Challenges Alzheimer’s, dementia or cognitive impairment: Confined to bed: Blind or low vision: Require constant care: Deaf or hearing impaired: Chronic condition (please specify): Speech impaired: Other (please specify): Limited mobility or difficulty walking: Primary language other than English: Dependency Dialysis: Insulin: Walker/cane/scooter/wheelchair: Ventilator: Oxygen: Other (please specify): Service animal: Power Dependent: Other machine dependent: Bariatric Bed: Table : Primary and Sister Facilities (See Attachment E) Primary Facility Facility Name Address (Street, City, State, Zip) County Contact Number Branch Offices Facility Name Address (Street, City, State, Zip) County Contact Number hour
Disaster Resiliency and NFPA Codes and Standards Refer to the National Fire Protection Association (NFPA) Standards in NFPA 101 Life Safety Code, and NFPA 1600, Disaster/Emergency Management and Business Continuity Programs Mississippi Emergency Access Program (MEAP) SITUATION Risk Assessment A Hazard Vulnerability Analysis (HVA) conducted by the <Insert name of entity> provides details on local hazards including type, effects, impacts, risk, capabilities, and other related data. Facility and MSDH County Medical HVAs located in Attachment 1 and 2 of the Continuity of Operations Annex and are provided by the Emergency Planner. <Insert the top five hazards from facility HVA> 1. 2. 3. 4. 5. CONCEPT OF OPERATIONS Incident Management Incident management activities are divided into four phases: mitigation, preparedness, response, and recovery. These four phases are described below. Mitigation: Mitigation activities are those that eliminate or reduce the possibility of a disaster occurring. For healthcare operations, this may include installing generators for backup power, installing hurricane shutters, and raising electrical panels to protect them from possible flood damage.<Insert Facility’s strategies for mitigation> Preparedness: Preparedness activities develop the response capabilities that are needed in the event an emergency occurs. These activities may include
Internal factors could include the physical structure of the facility, patient acuity, staffing, accessibility to critical supplies, availability of transportation assets for evacuation, and accessibility of possible evacuation destinations. External factors to be considered in making the decision to evacuate or shelter-in-place include the nature and timing of the event, the location or projected path of the threat (such as a flooding incident, ice storm, or hurricane), and the vulnerability of the facility to the threat. The chart below identifies hazards (Include the top five hazards from the county medical hazard vulnerability analysis (HVA) that can be provided by the Emergency Planner) that could necessitate the need for the evacuation or of patients and staff, who is responsible for making the decision, who is to be consulted, the timeline of activities, and factors that should be considered in deciding whether to evacuate or shelter-in-place. Complete the chart below based on the top five hazards from the county medical or facility HVA and additional threats faced by the facility that could necessitate either evacuation or shelter-in-place response activities. Table : Evacuation or Shelter-in-Place Decision Making Chart Hazard Decision Authority Alternate Consulting Parties Timeline Triggers for Evacuation Fire* Administrator* Director of Nursing* Facilities Manager, City Fire Chief* Immediately Location and intensity of fire Hurricane* Administrator* Director of Nursing* Emergency Management* 48 hours prior to arrival of tropical force winds Category, track and speed of storm *Examples Transportation Resources The <Insert name of facility> will identify appropriate resources to transport the patient population, staff, supplies, and necessary equipment in the event evacuation of the facility is necessary. The facility will seek to identify primary and back-up transportation providers with suitable vehicles and personnel to ensure adequate resources are available in an emergency. Ensure that the vendors or volunteers who will help transport patients and those who receive them at shelters and other facilities are trained on the needs of the chronic, cognitively impaired, and medically fragile population and are knowledgeable on the methods to help minimize transfer trauma. place
Attachment B: Mutual Aid Agreements/Memorandum of Understanding <Insert list of existing mutual aid agreements (MAA) and/or memorandum of understanding (MOUs)> MAAs/MOUs are stored <Insert location>. Table : Memorandum of Understanding/Mutual Aid Agreements Facilities/Agencies in Agreement Nature of Agreement Expiration Date (if applicable) Date Verified/POC Sysco* Emergency Food Supply* None* XYZ Hospital* Shelter* Ben’s transport service* Transport* Additional MOUs * Examples Attachment C: Routes to Evacuation Sites and Facility Floor Plans <Insert evacuation routes, floor plans, maps, and written directions to evacuation sites> Attachment D: Sample Hospital Incident Command System Forms Hospital Incident Command System (HICS) Forms can be provided by the Emergency Planner HICS 203 – Organization Assignment List HICS 207 – Hospital Incident Management Team Chart HICS 254 – Disaster Victim/Patient Tracking HICS 255 – Master Patient Evacuation Tracking HICS 257 – Resource Accounting Record HICS 260 – Patient Evacuation Tracking Form
<Insert Facility’s plan for establishing a family support center> This facility has pre-designated points for families to meet during an emergency where they will be given updates during the event on the patients and how the incident is being mitigated. At the time of the incident, families will be directed to this location upon arrival at the facility. These locations are subject to change due to the unknown nature of the incident. Communication with Vendors of Essential Supplies, Services, and Equipment The <Insert name of facility> has developed a list of vendors, contractors, and consultants that can provide specific services before, during, and after an emergency event. The <Insert position title> is responsible for maintaining the list. This list will be updated periodically. The list includes the name of the vendor and the supplies, services, or equipment provided to the patients, a phone number, and alternate contact information. Communication with Other Healthcare Organizations The <Insert name of Facility Liaison> will be responsible for providing key information to other healthcare organizations. Key information to be shared with other healthcare organizations in the community during a disaster includes: Command structures, including names and contact information for the command center, Resources and assets that can be shared, and Process for the dissemination of the names of patients and the deceased for tracking purposes. Communication about Patients to Third Parties <Reference Facility Health Insurance Portability and Accountability Act Plan/Policy> Backup Communications Redundancy and Equipment <Insert list of backup communications equipment and systems to be used in the event of telephone failure, which must include a communication plan (e.g., radios, runners)> Table : Communication Methods Primary Alternate Phone* Runner* Telephone* Cell phone, pager*