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Disaster
Preparedness Plan
and Procedures
STUDENTS and PROVIDERS
This form is provided as a guide and template to help you create your Disaster Preparedness
Plan and Procedure. This is provided as a guide only.
DO NOT USE AS-AS - REMOVE ALL YELLOW HIGHLIGHTED TEXT.
-- YOU MUST CUSTOMIZE THIS POLICY WITH YOUR DETAILS.
-- DELETE ALL INSTRUCTION WHEN COMPLETING THIS POLICY
-- REVIEW STUDENT MANUAL Module 6A pg 7 (sample DIsaster procedure)
Your AFH Name Here
AFH Address
Key Information
Utilities and Supplies Location
Water Shut-off
EXAMPLE: Shut-off valve is located inside the garage on the right-hand side, about 6’ from the
garage door on the south-facing wall.
Electric Panel
As above – location and details…
Gas meter and shut-off
As above – location and details…
Emergency Food Supply and Water
1. As above – location and details…
2. EXAMPLE: The 72-hour emergency food supply and potable water reserve is located near
the west exit door. There are also additional flashlights and new batteries.
3. *There is an additional water supply available inside the hot water tank located in bedroom
#5.
Hot Water Tank (contains 55 gallons of potable water)
As above – location and details…
First Aid Kit and First Response Manual
As above – location and details…
2
Disaster Preparedness Plan and Procedures
Your AFH Name Here
Floor Plan and Evacuation Map
Insert your floor plan here. Make sure you mark a clear “safe meeting location” which needs to
be about 50’ from the house. Also identify and mark the location of all utilities, your emergency
food and water supply, first aid supplies /kit, fire extinguishers and the exit path.
:: EXAMPLE PLAN FLAN - INSERT YOUR OWN ::
Local Evacuation Sites
Call 911 prior to evacuating or relocating any residents.
1. Evacuation site option 1: address, phone number, person in charge.
2. Evacuation site option 2: address, phone number, person in charge.
3. Evacuation site option 3: address, phone number, person in charge.
Disaster Preparedness Plan and Procedures
3
Chain of Command
Level of
Responsibility
Authority
Role
1
Provider
2
Resident
Manager
3
Lead Caregiver
4
9-1-1 / EMS
Name
Cell Phone
Important Names and Phone Numbers
INSERT THE APPROPRIATE PHONE NUMBERS FOR YOUR LOCATION
●
All Emergencies: 9-1-1
●
Current Provider:
●
RN Delegator:
●
RN Assessor:
●
Home Visiting MD:
●
Primary Pharmacy:
●
Secondary Pharmacy:
●
Ambulance (A.M.R.): (206) 444-4440
●
Cascade Cabulance: (800) 767-1717
●
Northwest Cabulance: (800) 600-9225
●
Fire Department – Seattle North end: (206) 386-1400
●
Police – Local: (999) 999-9999
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Disaster Preparedness Plan and Procedures
When to contact
Your AFH Name Here
●
Poison Center: 1-800 222-1222
●
Electric Power Outage - Local: (999) 999-9999
●
Gas utility supplier: (999) 999-9999
●
Waste Management - Local: (999) 999-9999
●
DSHS Case Manager:
Vendors the AFH Relies On
Vendor Name
Critical Resources
Supplied
Contact Name
Phone
Supplies to Purchase and Keep on Hand
(These are the bare essentials only. You should review and expand this inventory list.)
❏ Non-perishable food, including some that do not require cooking (at least 72 hours
supply per person including staff)
❏ Drinking water (one gallon per person per day, including staff)
❏ Food thickener?
❏ Water for hygiene and sanitation (important for incontinent residents)
❏ Sterile water for wound care (the amount depends on resident needs)
❏ Hydrogen peroxide 3%
❏ Rubbing Alcohol
❏ Povidone Iodine
❏ Normal Saline
❏ Paper plates, cups, napkins, disposable silverware…
❏ Can openers, knife
❏ Toilet paper, wipes,
❏ Hand Sanitizer
❏ First Aid supplies including,
Disaster Preparedness Plan and Procedures
5
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏ BandAids,
❏ Triple antibiotic ointment,
❏ Ace bandages,
❏ First Aid and CPR Manuals
Consumable medical supplies (gloves, creams, wipes, face masks, etc.)
Personal hygiene supplies
Flashlights with spare batteries - at least 6 + 2-3 for caregivers
Warm blankets + thermal blankets
AM/FM radio and extra batteries
Tools (such as a wrench for shutting off water and gas, screwdriver, hammer, pliers,
cutting tool(s), etc.)
Duct tape
Garbage bags
Work gloves
Other supplies as needed or desired
Reporting to ALTSA / DSHS in the event of an
evacuation:
In the event of an emergency evacuation of Residents from the AFH, the following information
will be reported to DSHS /ALTSA.
1.
2.
3.
4.
5.
6.
7.
8.
Date/time of evacuation (When?)
Method of evacuation (Who? How? What?)
The number of resident(s) evacuated (Who?)
Residence physical address (Where?)
The physical address of the location to which residents were evacuated (Where?)
Date/time of estimated return to primary residence (When?)
Plan to ensure the continuity of care (How?)
Any other pertinent information:
If further assistance in locating alternate placements for the evacuation of residents is needed,
please contact the local Home and Community Services (HCS) office. HCS Contacts by county
are available HERE...
For further support or additional emergency information, contact the local emergency
management services. A list of coordinators and contact, by county, is available HERE...
Further emergency planning resources are available on the ALTSA website HERE...
Provider’s Incapacity or Succession Plan:
Describe your plan for the continued operation of the AFH and the provision of care to your
residents in the event of an emergency.
6
Disaster Preparedness Plan and Procedures
Your AFH Name Here
See WAC 388-76-10201- Succession plan.
Epidemic or Pandemic Planning:
Describe your plan for infection control and AFH management during an epidemic or pandemic
outbreak. Review the DSHS, CDC, and DOH websites to understand guidelines that apply to
long-term care facilities.
Disaster Preparedness Plan and Procedures
7
Potential Disasters - Any:
As Soon As Possible
EXAMPLE OF WHAT TO ADDRESS - use this example to write your Disaster Plan and
Procedure.
1. Look for injured employees or residents. Help clear debris and care for the injured.
2. Extinguish all smoking materials. You may have a broken gas line, which could ignite a
fire/explosion.
3. Remain calm. Even though the main force of the disaster may be over, there may still be a
danger. For example, earthquakes are frequently followed by aftershocks and although the
hurricane is over, a tropical storm may still be in effect.
4. Do NOT leave your facility until it has been determined that travel is safe.
5. Conduct a complete safety inspection as soon as possible after the disaster.
6. Assess the damages and call your insurance carrier or retain the services of a property
damage and liability insurance carrier. Check for:
▪
Structural Damage – Block access to areas where structural damage is apparent.
▪
Damage to Water Pipes – Shut off water supply – block access to flooded area until the
water on the floor can be cleaned up.
▪
Damaged Electrical Outlets or Cords – Shut off electrical power or discontinue use until
repaired.
▪
Loose Lighting Fixtures, Cabinets, Shelves, Etc. – Block access to the area until
repaired.
▪
Broken Windows and Doors – Tape or take other measures to secure loose glass.
▪
Keep employees out of these areas until repairs have been made.
▪
Gas Leaks – Shut off the gas supply. Prohibit smoking on the premises.
▪
Stairways – Remove any debris, secure handrails and block access until repaired.
▪
Fuse Boxes or Circuit Breakers – Shut off power until repaired.
▪
Fire, First Aid and Other Safety Equipment – Check for damage and make accessible.
▪
DO NOT USE if damaged; replace as soon as possible.
▪
Chemicals – Inspect for leaks, spills or damage to the container. Follow safety
precautions as outlined on the appropriate Material Safety Data Sheets (MSDS).
Prepare for Possible Power Outages
How should you and your staff prepare for power outages?
8
Disaster Preparedness Plan and Procedures
Your AFH Name Here
Wildfire
How will you and your staff deal with a fire or wild-fire? List step-by-step instructions.
Earthquake
How will you and your staff deal with a fire or wild-fire? List step-by-step instructions. See
examples below...
Prepare a Home Earthquake Safety Plan
▪
Choose a safe place in every room – under a sturdy table or desk or against an inside
wall where nothing can fall against you.
▪
Practice DROP, COVER, AND HOLD ON at least twice a year. Drop under a sturdy desk
or table, hold on, and protect your eyes by pressing your face against your arm. If
there’s no table or desk nearby, sit on the floor against an interior wall away from
windows, bookcases or tall furniture that could fall on you. DROP, COVER AND HOLD
ON!
▪
Know what to do when the shaking begins
▪
DROP, COVER AND HOLD ON! Move only a few steps to a nearby safe place. Stay
indoors until the shaking stops and you’re sure it’s safe to exit.
▪
Identify what to do after the shaking stops
▪
Check yourself for injuries. Protect yourself from further danger by putting on long
pants, a long-sleeved shirt, sturdy shoes and work gloves.
▪
Water in an Emergency
How will you and your staff address water needs during a disaster or emergency? List step-bystep instructions.
How to Store Water
Disaster Preparedness Plan and Procedures
9
Emergency Outdoor Water Sources
If you need water outside your home, you can use these sources. Be sure to purify the water
according to the instructions listed under “Three Ways to Purify Water” before drinking it.
▪
Rainwater.
▪
Streams, rivers and other moving bodies of water.
▪
Ponds and lakes.
▪
Natural springs.
Avoid water with floating material, an odor, or dark in color. Use salt water only if you distill it
first. You should NOT drink flood water.
Ways to Purify Water
Details
Boiling
Details
Disinfection
Details
Distillation
Details
Food in an Emergency
How will you and your staff address food needs? List step-by-step instructions.
When Food Supplies Are Low
Details
Special Considerations
Details on foods that require refrigeration, special diets that residents may be on, etc.
If the Electricity Goes Off
How will you and your staff address resident care and AFH operation during power outages?
List step-by-step instructions.
10
Disaster Preparedness Plan and Procedures
Your AFH Name Here
How to Cook If the Power Goes Out
Details
Floods
How will you and your staff deal with a potential flood? List step-by-step instructions. See
examples.
Before a Flood
▪
Know what has occurred to local property during past floods and take appropriate
actions.
During a Flood
If there is time:
▪
Disconnect all electrical and gas appliances. Shut off the water main to keep
contaminated water from the water heater (a source of emergency drinking water).
▪
Evacuation
▪
Evacuate the most ambulatory or independent residents first, and then proceed to
evacuate those residents who require more help.
▪
After a Flood
▪
Return to home ONLY after authorities say it is safe.
▪
Disaster Preparedness Plan and Procedures
11