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
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
Staff/Patient Re-Entry The <Insert position title> will work with the Bureau of Health Facilities Licensure and Certification to give approval for the return of staff and patients to the facility. The coordination of the return of staff and patients to the facility will be the responsibility of the <Insert position title>. <Insert list preparations and procedures for returning patients after an emergency (e.g., transport of patients back to the facility and related activities)> Staff Debriefing A debriefing will be conducted within <Insert number of hours> of the incident to collect lessons learned from the incident or exercise. These lessons learned will be used to revise and update the plan. The <Insert position title> will be responsible for coordinating the debriefing. After-Action Report/Improvement Plan After any real incident or exercise where the emergency operations plan is activated, an after-action report and an improvement plan will be developed. The purpose of the report is to document the overall performance of the organization during the exercise or real event. It will contain a summary of the scenario or events, staff actions, strengths, issues, opportunities for improvement, and best practices. The purpose of the improvement plan is to ensure issues and opportunities for improvement are adequately addressed to improve response capabilities to future events. The improvement plan will include a list of issues to be addressed, tasks that will be performed to address them, individuals responsible for completing the tasks, and a timeline for completion. The <Insert position title> will be responsible for coordinating the development of the after-action report and improvement plan and will ensure identified corrective actions are completed within the targeted timeframes. GLOSSARY Activation - When all or a portion of the plan has been put into motion. After-Action Report (AAR) - A report that includes observations of an exercise or real event and makes recommendations for improvements. The purpose of the after-action report is to document the overall performance of the organization during the exercise or real event. It will contain a summary of the scenario or events, staff actions, strengths, issues, opportunities for improvement, and best practices.