Emergency
Planning Guide
For Assisted Living Facilities
South Carolina Association of
Residential Care Homes
Published May 2012
Facility Name: ____________________________________________
Facility Address: __________________________________________
Date Prepared: ______/______/_______
INTRODUCTION______________________________________
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© 2012 South Carolina Association of Residential Care Homes
Hurricanes, tornadoes, earthquakes, wildfires, winter storms, and other emergencies
can happen in South Carolina. This document will assist you in preparing to manage
your facility during any emergency affecting your assisted living home. An assisted
living/residential care home must have disaster preparedness and emergency
evacuation plan approved by the state’s licensing agency. This template incorporates
State of South Carolina Assisted Living home requirements into additional
preparedness activities that you should undertake to ensure the safety of your residents
and staff. Whether you are using this template as part of your application process or if
you are using it to enhance your existing plans, you should submit it to your state
licensing specialist upon completion.
The SCARCH Emergency Plan is provided as a service by the South Carolina
Association of Residential Care Homes and is intended as guidance in developing
emergency plans in facilities. This document is not intended as legal advice and should
not be relied upon as such. Providers should consult with the South Carolina
Department of Health and Environmental Control to ensure the emergency plan is
complete and well suited for your individual facility.
LIMITATIONS
This guide is not a completed emergency planning guide. No guarantee is implied by
this planning guide. All facilities are encouraged to personalize the plan so that it meets
their specific needs. It is imperative that each staff member understand his/her roles
and responsibilities in any given situation. Planning should never be a one-person effort.
Facility staff, residents, and residents’ relatives should be included in the planning
process whenever possible. Experience has shown that plans are less likely to be used
or are less effective during an emergency if there has been little participation in the
planning process.
ADDITIONAL RESOURCES
SC Department of Health & Environmental Control
http://www.dhec.sc.gov/health/licen/emergency.htm
Centers for Disease Control & Convention
www.cdc.gov/healthywater/pdf/emergency/emergency-water-supply-planning-guide.pdf
American Red Cross
www.redcross.org/pubs/dspubs/genprep.html
Federal Emergency Management Agency
http://www.fema.gov/plan/index.shtm
US Department of Homeland Security
http://www.ready.gov
TABLE OF CONTENTS
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I.
DEVELOPING YOUR PLAN
6-8
II.
GENERAL INFORMATION
9-11
II.
EMERGENCY ORDERS
12-13
III.
INCIDENT –SPECIFIC
14-20
IV.
DISASTER SUPPLY KITS
21
V.
SHUTTING DOWN UTILIIES & EXTINGUISHER USE
22-23
VI.
EVACACUATION ROUTE & EMERGENCY CONTACTS
24-25
VII.
MEDICAL EMERGENCY
26
VIII. FIRE EMERGENCY
27
IX.
EXTENDED POWER LOSS
28
X.
CHEMICAL SPILL
29
XI.
STRUCTURE CLIMIBNG/DESCENDING EMERGENCIES
30
XII.
BOMB THREAT CHECKLIST
31-32
XIII.
EXTREME WEATHER & NATURAL DISASTERS
33-34
XIV.
CRITICAL OPERATIONS & TRAINING
35
XV.
EMERGENCY PLAN CHECKLIST
37-38
XVI.
EMERGENCY INFORMATION REQUIRED
39
XVII. EVACUATION FROM FACILITY
40
XVIII. TORNADOS
A. Sample Pre-Hurricane Season Letter to Families
41
42
XIX.
FIRE PLAN
43
XX.
XXI.
HURRICANES
EARTHQUAKE
44-45
46
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XXII. MISSING RESIDENT
47
XXIII. NEWS MEDIA RELEASE OF INFORMATION
48
XXIV. DHEC: EMERGENCY EVACUATION PLAN ORDER
49-50
XXV. DHEC: EMERGENCY EVACUATION PLAN SUBMISSION REQUIREMENTS
51-52
XXVI. DHEC: EVACUATION PLAN COMPONENTS
53
XXVII. EVACUATION PLAN STATEMENT
54-55
XXVIII. ATTACHMENTS (FORMS)
56-83
A. Checklists
Attachment
Attachment
Attachment
Attachment
Attachment
Attachment
Attachment
Attachment
Attachment
Attachment
Attachment
Attachment
1:
2:
3:
4:
5:
6:
Emergency Contact Roster- Internal Staff ……..56-58
External Contact Information ……………………….59-60
Disaster Family Care Plan …………………………….61
Notification Procedures Checklists …………………62
Evacuation Checklists ………………………………….63-65
Extended Care Facility Resident Census and
Conditions to be used for Disaster Evacuation
Planning and Reporting…………………………..……65
7: Shelter-in-Place Checklists ……………………………66-68
8: Recovery Checklist ………………………..…………….69-71
9: Hurricanes Preparedness & Evacuation
Checklists ……………………………………………………72-74
10: Checklists for Other Natural Disasters ………… 75-77
11: Technological Disaster Checklists…………………78-82
12: Checklist for Other Disasters …………………….. 83-84
CDC Checklist for Pandemic Influenza ………… 84
XXXIX. Facility Department Responsibilities: Job Action Sheets
85-89
A. Administration ……………………………………………………….…... 85-86
B. Dietary/Food Services …………………………………………………. 86
C. Housekeeping Services ………………………………………….……. 87
D. Maintenance Services …………………………………………………. 87-88
E. Nursing/Medical Services …………………………………………….. 88
F. Patient Services ………………………………………………………….. 89
G. Transportation Checklist ……………………………………………… 90
XXXXX. Event Reporting
91
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© 2012 South Carolina Association of Residential Care Homes
PREPARED BY:
South Carolina Association of
Residential Care Homes
Melody Bailey, Executive Director
4721D Sunset Blvd.
Lexington, SC 29072
Phone (800)862-2908
Fax (803)951-2136
www.scarch.org scarch@scarch.org
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DEVELOPING YOUR PLAN_____________________________
To help you understand the planning process and to know what you are planning for,
you will want to take some time to go through this section to gather information, to gain
knowledge and to make some assessments about your staff and facility to help you
complete your written plan.
1. Know who will be affected by your plan.
• Residents
• Staff
• Residents’ loved ones
2. In addition to building-specific emergencies, be aware of what hazards may
affect your local city.
NATURAL
Hurricane
Earthquake
Wildfire
Extreme Weather
Flooding
Avalanche
Ground Failure/ Landslide
Severe Erosion
Infectious Disease
Food/Water Contamination
TECHNOLOGICAL
Dam Failure
Energy Emergency
Urban Fire
Hazardous Materials
Release
Power Failure
Radiation Release
Transportation Accident
Air Pollution
Communications Failure
HUMAN/SOCIETAL
Civil Disturbance
Terrorism–including
chemical, biological,
radiological, nuclear, or
explosive agents
3. Know how you will obtain information during an emergency.
If the emergency affects only a small area of the community, the police or fire
department may notify you by going door-to-door in the affected area. For emergencies
affecting a large area of the community, the city will issue an emergency alert via the
Emergency Alert System (EAS), Be sure you have a battery-operated radio and extra
batteries in your disaster supply kit.
4. Identify evacuation locations.
Designate two places for everyone to meet and make sure all of the residents’
emergency contacts know where the alternate sites are located.
• One evacuation location should be located directly outside the facility, such as
the end of the driveway or an adjacent property.
• A second evacuation location should be in a different part of town in the event
that you need to move further away from the facility such as a community
recreation center, a church, or a hotel lobby. Check with the facility first for
approval.
If weather or other circumstances prevent you from using your evacuation sites, the city
can provide additional sheltering options.
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5. Develop a communications plan
Make sure that loved ones know how to reach you if you have evacuated the facility and
make sure you know how to reach them. It’s a good idea to include contact information
in your disaster supply kit.
Identify an out-of-area phone contact for families of staff and residents to call during a
large-scale emergency. Out of area phone numbers often work better than local phone
numbers during emergencies. If your facility has restricted the long-distance calling
feature, be sure you have calling cards available to use during an emergency.
If the power is out, many modern phones or phones with built in answering machines
will not work because they require electricity to operate. Be sure you have a phone on
hand that plugs in only to the phone jack and not into an electrical outlet so that you can
call for help if necessary.
6. Create a disaster supply kit.
Make sure your facility has a disaster supply kit and adequate supplies to sustain your
staff and residents for 5 to 7 days if necessary.
7. Be prepared to shelter-in-place.
Familiarize yourself with shelter-in-place procedures and identify a “safe spot” in the
facility should sheltering-in-place become necessary.
8. Know how to shut off your utilities. Look for gas lines in kitchen, laundry room, etc.
9. Know how to operate and maintain your fire extinguishers.
• All staff should know where fire extinguishers are located and how to use them.
• Like any mechanical device, fire extinguishers must be maintained regularly to
ensure their proper operation.
10. Write your plan
Using the information you have gathered in the previous steps, fill in the blanks of the
model disaster plan, and customize it to meet the needs of your facility. You should
modify any of the narrative that does not adequately meet the needs or capabilities of
your facility. You will need to send for review & get a written statement of approval from
local fire marshall and DHEC emergency disaster office.
11. Provide a copy of your plan to your state licensing representative.
If this plan is part of your initial application, this step is a requirement. If you used this
template to update your existing plan, you may still want to forward your new plan for
their records.
12. Distribute the plan to all each staff member, each resident, and each
resident’s family.
13. Determine what staff training may be needed and create a timeline for training
completion.
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14. Conduct fire and emergency drills as required by state regulations and
remember to document the results.
15. Review your plan with your staff every six months or after any emergency
requiring its use.
If a problem is identified during a review, develop a solution and practice the new
procedure. If this resolves the problem, modify your plan to reflect the change and
supply a copy of the modified plan or section to each staff member, resident, residents’
families, and to the state licensing authority.
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GENERAL INFORMATION________________________
Comprehensive emergency plan for:_____________________________________________________________
Assisted Living Facility Name
This assisted living facility is owned & operated by:___________________________________________________
Manager
Facility address: _____________________________________________________________________________
Facility contact number(s): _____________________________________________________________________
The out-of-area contact for this assisted living facility is:_______________________________________________
Name / phone number
Types of emergencies that could occur in this area are:
• Hurricane
• Tornado
• Wildfire
• Extreme Weather
• Flooding
• Ground Failure/ Landslide
• Severe Erosion
• Infectious Disease
• Food/Water Contamination
• Dam Failure
• Energy Emergency
• Urban Fire
• Hazardous Materials Release
• Power Failure
• Radiation Release
• Transportation Accident
• Air Pollution
• Communications Failure
• Civil Disturbance
• Terrorism
Our first aid kit is located: ________________________________________________________________________
You may want to attach a floor plan with fire extinguishers located on it.
Our fire extinguisher(s) are easily accessible and located in plain sight at the following location(s):_______________
_____________________________________________________________________________________________
Our disaster supply kit is located: __________________________________________________________________
It contains: ____________________________________________________________________________________
_____________________________________________________________________________________________
If an emergency requires an evacuation, we have established two evacuation sites. If offsite evacuation is required,
we will place a sign at the facility entrance to notify resident’s loved ones and emergency responders of our location.
1. Just outside the assisted living home we will meet at:_________________________________________________
2. If evacuation to a location further away from the facility is required we will evacuate to:_______________________
_____________________________________________________________________________________________
You may want to add an addendum with a list of resident room numbers, names, amulation status & any limitations.
Our procedures for evacuating residents with limited mobility or who are mentally or visually impaired are
as follows: ____________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
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EMERGENCY PERSONNEL NAMES AND PHONE NUMBERS
EMERGENCY COORDINATOR:
Name:_______________________
_____
Phone: (____)_______________
AREA/FLOOR MONITORS (If applicable):
Area/Floor:___________________
Name:_______________________
Phone: (_____)________________
Area/Floor:___________________ _______
Name:_______________________
Phone: (_____)________________
ASSISTANTS TO PHYSICALLY CHALLENGED (If applicable):
Name: __________________________________
Phone: (_____)________________
Name: _________________________
Phone: (_____)________________
Administrator:
Name: __________________________________
Phone: (_____)________________
Safety Director:
Name: __________________________________
Phone: (_____)________________
Director of Resident Care/Nursing:
Name: __________________________________
Phone: (_____)________________
Marketing Director:
Name: __________________________________
Phone: (_____)________________
Maintenance Director:
Name: __________________________________
Phone: (_____)________________
Food Service Director:
Name: __________________________________
Phone: (_____)________________
Date ____/____/____
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The following major steps have been taken toward preparing our assisted living home.
�YES � NO
The out of area contact number has been provided to loved ones of residents
who have been instructed to call this number if they cannot get through to the
local phone number during or after an event.
�YES � NO
We have posted emergency numbers and the building address by each phone
that is used in the assisted living home.
�YES � NO
An emergency exit plan is posted at each entrance/exit door.
�YES � NO
All staff members have been trained on how and when to shut off utilities to the
facility.
�YES � NO
Emergency telephone numbers are posted in plain sight and residents are
informed to call 911 if directed in the event of an emergency or if informed to do
so by staff.
�YES � NO
Upon admission and at least monthly thereafter, residents are advised of the
outdoor area that is the designated meeting place in the event of an emergency.
�YES � NO
Upon admission and at least annually thereafter, capable residents receive
training in first aid, fire, and evacuation procedures.
�YES � NO
Water and food stored for disasters are rotated every six months.
�YES � NO
At least one staff person in the facility is current in First Aid and CPR.
�YES � NO
Each room has at least two escape routes.
�YES � NO
The emergency plan is reviewed every six months with employees and whenever
a new staff person is hired.
�YES � NO
Fire extinguishers are examined monthly and recharged as recommended by
the manufacturer.
�YES � NO
There is a smoke detector inside each resident’s bedroom and a carbon
monoxide detector on each level of the home.
�YES � NO
Smoke and carbon monoxide detectors are checked monthly and batteries are
replaced twice annually if battery-powered.
�YES � NO
We have at least one battery-powered radio with extra batteries.
�YES � NO
We have working flashlights, including flashlights at each resident’s bedside
table, in the assisted living home.
�YES � NO
We have a list of residents who do not have a relative who can pick them up after
a disaster.
�YES � NO
Each resident has an “emergency duffel bag” under his/her bed, which contains
the following supplies: _______________________________________________
___________________________________________________________________
___________________________________________________________________
�YES � NO
A first aid book and quick reference chart is located in the common area for
residents.
(If you have answered no to any of these questions, please explain on a separate sheet of paper.)
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EMERGENCY ORDERS__________________________
At the outset of an emergency, the facility administrator or lead staff on duty will
designate an initial emergency order based on what is appropriate for the emergency.
911 will be called any time there is a life-threatening emergency. Initial emergency
orders may be one of the following:
• Drop-cover-hold
• Evacuate
• Lockdown
• Shelter-In-Place
As information about the emergency becomes known and as conditions change, the
initial order may be amended by the facility administrator or lead staff. In an earthquake,
for instance, residents and staff may be told to duck-cover-hold until the shaking stops,
and then be told to evacuate the building.
Emergency responders may be able to help the facility administrator or lead staff
decides if, when, or how orders should be changed.
DROP-COVER-HOLD
The need to drop-cover-hold is generally obvious such as during an earthquake or
explosion.
Staff shall immediately ensure that able residents:
1. Drop to the floor
2. Get under a table or other sturdy piece of furniture.
3. Hold on to a table leg or other stable support during an earthquake.
4. Remain until the order is rescinded or revised by the administrator or lead staff.
Residents who are unable to drop-cover-hold should:
1. Move away from windows.
2. Protect their head using a pillow if possible.
3. Avoid moving around as much as possible.
Residents and staff caught outdoors should:
1. Move away from electrical wires, buildings or other structures that could collapse.
2. Get down and cover their heads if possible.
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LOCKDOWN
Lockdown may be appropriate for an active attack or an intruder. Any staff member
sensing an imminent threat to life is authorized to call a lockdown. This condition is
maintained until the order is rescinded or revised by a recognized authority.
Staff shall immediately ensure that:
1. All residents are accounted for.
2. Residents get down and seek cover away from windows and doors.
3. All doors and windows are closed and locked.
4. All lights are turned off.
5. Doors and/or windows are covered, as appropriate, based on the threat.
SHELTER-IN-PLACE
This action may be appropriate for a hazardous materials incident. The shelter-in-place
command is given by the facility administrator or lead staff. The order may be based on
observations reported to the front office by third parties. This condition is maintained
until the order is rescinded or revised by a recognized authority
Staff shall immediately ensure that:
1. All residents outdoors are brought inside.
2. All building entrance/exit doors and all exterior windows are closed and locked.
3. All rooms with an exterior wall are abandoned.
4. The heating system is shut down especially if it is a forced air system.
5. Using duct tape, abandoned rooms are converted to dead air spaces.
6. Roll will be taken, if possible.
EVACUATE
This action may be appropriate for fire, active attack, bomb threat, post-earthquake
damage, wildfire, or facility fire. Evacuation may be the initial emergency order. It is
always appropriate in the case of a facility fire, for instance. An evacuation could be
called as a secondary action. With earthquakes, for example, evacuation may follow a
drop-cover-hold for an inspection of the facility for damage. In an active attack,
evacuation could be preceded by a brief lockdown period.
During an evacuation, staff will ensure that:
1. Residents remain calm and organized.
2. Emergency duffel bags are taken if time permits.
3. Disaster supplies kits are taken.
4. Residents are assembled for roll call at pre-planned staging areas when possible.
5. Any posted evacuation routes are followed if conditions permit.
6. Notice is posted, if time permits, as to where residents have evacuated.
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INCIDENT-SPECIFIC CHECKLISTS_________________
This facility has established checklists of procedures to be followed in the different emergency events
described below:
Aircraft accident
Incident with serious injuries
Animal problem
Death at Facility
Earthquake
Explosion
Fire in facility
Fire near facility
Flood
Intruder
Loss of utilities
Bomb Threat
Suspicious item
Windstorm
These checklists will aid the assisted living administrators and staff in managing emergencies, particularly
those that are drawn out in time and/or are a component of a larger, community-wide, disaster.
Emergencies not appearing on this list may occur, but the lists still contain measures that might be helpful
to staff trying to decide how best to respond.
The lists are not all inclusive. Additional measures may be required as an incident progresses.
Conversely, events may unfold in such a way that some items on the checklist are rendered unnecessary,
or counter-productive. The checklists are there to remind staff of measures likely to be useful and worthy
of consideration.
AIRCRAFT ACCIDENT
1. Consider an initial emergency order based on the size of the aircraft, nature of the crash, and the
impact location relative to the facility. If the facility is safe, residents should be kept indoors.
• Shelter-in-place
• Evacuation
2. Call 911 if necessary
3. Evacuate if necessary. Change telephone message and leave information posted on facility door or
window. Once at the evacuation point, notify residents’ emergency contacts. Do not return to the facility
until buildings have been declared safe by officials
4. If structural damage is suspected, arrange for a structural inspection or contact a qualified engineer.
5. Log activities, decisions, and communications as soon as possible.
6. Debrief staff and review actions taken to consider whether emergency procedures were effective.
7. Amend plan as necessary based on review.
INCIDENT WITH SERIOUS INJURIES
1. Consider an initial emergency order.
• Lockdown (ex: onsite violent crime)
• Evacuate (ex: earthquake has rendered facility unstable)
2. Call 911 to report serious injuries.
3. Trained staff administers first aid.
4. Notify emergency contacts of affected residents.
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5. If a crime is committed, meet with police and assist in investigation as requested. Obtain and record
case number for your records.
7. Reassure concerned residents and/or relatives regarding safety precautions at facility.
8. Log activities, decisions, and communications as soon as possible.
9. Debrief staff and review actions taken to consider whether emergency procedures were effective.
10. Amend plan as necessary based on review.
ANIMAL PROBLEM
1. If life threatening, call 911.
2. Confirm that police are notifying Animal Control, as appropriate.
3. Monitor the situation, and act as necessary.
4. Keep residents isolated from the animal
5. Keep track of the animal’s location to the extent possible
6. If animal injures someone, see accident/incident with serious injuries checklist
7. Log activities, decisions, and communications as soon as possible.
8. Debrief staff and review actions taken to consider whether emergency procedures were effective.
9. Amend plan as necessary based on review.
DEATH AT FACILITY
1. Do not move body, or disturb evidence or immediate surroundings.
2. Clear residents from area
3. Call 911.
4. Do not phone next of kin if death was not from natural causes. Death notification will be made by the
police.
5. If facility administrator is not on premises, contact them to respond to scene.
6. Log activities, decisions, and communications as soon as possible.
7. Debrief staff and review actions taken to consider whether emergency procedures were effective.
8. Amend plan as necessary based on review.
EARTHQUAKE
1. Drop-cover-hold
2. Call 911 after the shaking stops only if there is a life-threatening emergency.
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3. Avoid glass and falling objects. Move away from windows where there are large panes of glass and
heavy suspended light fixtures
4. Inspect facility after the shaking stops or as soon as it is safe. If damage is apparent, consider
evacuation
5. If structural damage is suspected, call to request a structural inspection.
6. Warn all personnel to avoid touching electrical wires
7. Determine a secondary emergency order:
a. If shelter-in-place is selected, begin planning for food, shelter, and sanitation requirements;
secure disaster supplies kit
b. If evacuation is selected, secure disaster supplies kit and retrieve emergency duffel bags;
instruct staff to take all personal items, including vehicle keys; change telephone message
and post information on facility door or window. If evacuating, do not use exit routes that have
heavy architectural ornaments over entrances/exits
8. Obtain available information on the magnitude of the disaster; try to determine if aftershocks, fires,
hazmat incidents, etc. are expected that may affect personnel, residents, or the facility.
9. Log activities, decisions, and communications as soon as possible.
10. Debrief staff and review actions taken to consider whether emergency procedures were effective.
11. Amend plan as necessary based on review.
EXPLOSION
1. Select an initial emergency order:
• Drop-Cover-Hold
• Shelter in place
2. Move residents away from windows and out from under light fixtures to avoid glass and falling objects if
possible.
3. Call 911
4. When the event is over, inspect the facility if it is safe to do so. If structural damage is apparent,
consider evacuation.
5. If evacuating, change telephone message and leave information posted on facility door or window.
Once at the evacuation point, contact relatives
6. If evacuating, do not use routes that have heavy architectural ornaments over entrances/exits
7. Look for indications suggesting whether the explosion was accidental or intentional. Preserve evidence
8. If bombing is suspected, be alert for unexploded secondary devices and report them. Do not touch
anything that appears suspicious
9. Be wary of the possibility of nuclear/biological/chemical dispersal.
10. Warn all staff to avoid touching all electrical wires.
11. Log activities, decisions, and communications as soon as possible.
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12. Debrief staff and review actions taken to consider whether emergency procedures were effective.
13. Amend plan as necessary based on review.
FIRE IN FACILITY
1. Confine the fire by closing the door to the area involved.
2. Extinguish the fire if it can be done so safely, such as a small kitchen fire.
3. Order an evacuation immediately if the fire cannot be put out quickly.
4. Call 911.
5. Do not return to the facility until instructed by the fire department.
6. If applicable, maintain a list of persons removed by ambulance, including name of intended hospital
7. Notify family members of any affected residents.
8. Log activities, decisions, and communications as soon as possible.
9. Debrief staff and review actions taken to consider whether emergency procedures were effective.
10. Amend plan as necessary based on review.
FIRE NEAR FACILITY (Wildfire or other structural):
1. Evacuate, if necessary.
2. If not evacuating, call 911 to ensure the fire has been reported.
3. Monitor the situation visually and listen to the radio for any changes in incident status.
4. Log activities, decisions, and communications as soon as possible.
5. Debrief staff and review actions taken to consider whether emergency procedures were effective.
6. Amend plan as necessary based on review.
FLOOD
1. Select an Initial emergency order based on the extent of the flooding:
• Evacuation
• Shelter-in-place
2. Call 911, if necessary
3. If evacuating, do not return to the facility until it has been declared safe by the police department, the
fire department, or municipal building safety officials
4. If structural damage is suspected, request a structural inspection by calling the Emergency
Management Center at _______________________.
5. Log activities, decisions, and communications as soon as possible.
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6. Debrief staff and review actions taken to consider whether emergency procedures were effective.
7. Amend plan as necessary based on review.
INTRUDER
1. Notify another staff member, then approach and greet the person to ascertain his/her reason for being
at the facility
2. If the person refuses to leave, take reasonable steps to insulate the residents. This could mean
clearing residents from a room or hall, clearing an outdoor area, or calling a lockdown
3. Call 911 and report the incident.
4. If you can safely do so, keep an eye on the person, and keep APD advised of his/her whereabouts and
any weapons the intruder might have.
5. Log activities, decisions, and communications as soon as possible.
6. Debrief staff and review actions taken to consider whether emergency procedures were effective.
7. Amend plan as necessary based on review.
LOSS OF UTILITIES
1. Call the pertinent utility and determine the extent of the outage
2. Determine if utility loss is a nuisance (no lights in May) or a hazard (no heat in December)
3. Determine the scope of the outage. Is it just the facility, the entire neighborhood, or the entire city?
4. Try to determine how much time will be required to correct the problem
5. Considering the collected information, determine an initial emergency order:
• Consider shelter-in-place if utilities are to be restored soon.
• Consider evacuation if prolonged occupation of the facility is inadvisable.
6. Log activities, decisions, and communications as soon as possible.
7. Debrief staff and review actions taken to consider whether emergency procedures were effective.
8. Amend plan as necessary based on review.
BOMB THREAT – caller on phone
1. Keep caller on the phone as long as possible
2. Motion to someone else to call 911 on another line.
3. That second person should relay the following information to the 911 dispatch:
a. Time threat call received
b. Phone extension receiving threat call
c. Request that a police officer respond to the facility
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4. Do not use cell phones until approved by police
5. Assist in securing the facility or area, if applicable
6. Evacuate if instructed by the facility administrator or lead staff, following regular evacuation
procedures.
7. Assist police in walk-through scan for suspicious items if requested to do so.
8. Log activities, decisions, and communications as soon as possible.
9. Debrief staff and review actions taken to consider whether emergency procedures were effective.
10. Amend plan as necessary based on review.
BOMB THREAT – written or recorded message
1. Call 911
2. If message is by email or fax, print message and read verbatim to 911 dispatch. Give originals to the
responding officer
3. If message is a paper note, read verbatim to 911 dispatch. Give originals to the responding officer
making efforts to preserve the suspect’s fingerprints on the paper.
4. Do not use cell phones until approved by police.
5. Assist in securing the facility or area, if requested.
6. Evacuate if instructed by facility administrator or lead staff following regular evacuation procedures.
7. Assist police in walk-through scan for suspicious items, if requested.
8. Log activities, decisions, and communications as soon as possible.
9. Debrief staff and review actions taken to consider whether emergency procedures were effective.
10. Amend plan as necessary based on review.
SUSPICIOUS ITEM
1. Do not touch device or suspicious object
2. Evacuate immediate area (and keep others away)
3. Call 911
4. Turn off cell phones and radios
5. Assist police in walk-through scan for suspicious items if requested to do so.
6. Log activities, decisions, and communications as soon as possible.
7. Debrief staff and review actions taken to consider whether emergency procedures were effective.
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8. Amend plan as necessary based on review.
WINDSTORM
1. Select an initial emergency order based on the severity of the event:
• Duck-cover-hold
• Shelter-in-place
2. Call 911 if life-threatening emergencies occur.
3. Ensure that all windows and blinds are closed
4. Clear the side of the facility bearing the full force of the wind
5. If the facility is multi-storied, relocate the occupants to the lower floor near the inside walls.
6. Keep tuned to a local radio station for latest advisory information
7. Upon passage of the storm, initiate any other appropriate action, or return to normal routine.
8. Log activities, decisions, and communications as soon as possible.
9. Debrief staff and review actions taken to consider whether emergency procedures were effective.
10. Amend plan as necessary based on review.
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DISASTER SUPPLIES KITS
EMERGENCY DUFFEL BAG CONTENTS
We recommend- Each resident should be required to have an “emergency duffel bag” under his/her bed,
which will contain the following items:
• Warm clothing
• Underwear
• Thick blanket
• Pair of socks and shoes
• Towel
ASSISTED LIVING HOME DISASTER SUPPLIES KIT
Each assisted living home will have a disaster supplies kit. The disaster supplies kit should be kept on the
ground floor of the house. Consider placing these items in a large wheeled trashcan. Note that the size
and complexity of this kit will be related to the size of the facility.
The kit should include the following:
• Canned and dried foods sufficient for at least five to seven days for all residents and staff
• One gallon of water per person per day for five to seven days
• Manual can opener
• Battery-powered radio*
• Flashlights*
• Extra batteries*
• Matches in a waterproof container
• Candles
• First aid kit
• Lightweight, compact blankets, or space blankets
• Sanitation items (toilet paper, paper towels, moist towelettes, soap, plastic garbage bags, etc.)
• Copy of the disaster plan
• Copy of all residents’ emergency records
• Whistle
• Extra clothing
• Medication
• First Aid Kit
• Large trash bags to act as rain ponchos or waste disposal
• Small amount of cash
You may also want to keep on hand a telephone that can be plugged directly into the wall without a power
outlet, so you can still call for help if the power is out.
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SHUTTING DOWN YOUR UTILITIES
GAS
If an earthquake affects your home, you will need to make a determination
whether you need to shut down your gas or your gas appliances. Never turn
off your gas unless you smell or hear gas leaking.
1. Stay calm and carefully check your gas pipes and gas appliances for
the sound of escaping gas.
2. If an appliance is leaking gas, identify the shutoff valve where it connects
with your gas supply. Close the appliance shut-off valve to stop the leak.
3. If your main gas line is leaking, evacuate your home immediately.
• Do not turn on a light switch
• Do not smoke
• Do not use a match or candle if the power is out; use a flashlight
• Do not pick up your phone
4. If your main gas line is leaking and you feel you can safely shut off the gas,
evacuate your residents and staff first and then shut down your gas supply.
Keep your gas meter free from ice, snow, or other obstructions.
a. Keep an 8”-12” adjustable wrench handy to turn off the gas. You
should store it near your gas meter or in your disaster supply kit.
b. Find the gas meter shutoff valve. It is usually the first fitting on the
gas supply pipe coming out of the ground near your meter.
c. Use the wrench to turn the valve one-quarter turn in either
direction so the valve is crosswise to the pipe.
d. Once the gas is off, leave it off. Do not attempt to restore your gas
service. Only an ENSTAR or other qualified service technician can
restore your gas.
5. If you cannot shut off your gas supply to your home safely, go to a neighbor
or other safe place and call 911 to report the gas leakage. Do not use the
phone in your facility.
WATER
You will need to protect the water sources already in your home from
contamination if you hear reports of broken water or sewage lines, or if local
officials advise you of a problem.
1. Know where your water shutoff valve is located.
• Residential plumbing code requires the water shutoff valve to be
located within 10 feet of the crawlspace access when it is located
in the crawlspace.
• Other places to look would be at or near the water heater in the
garage or mechanical room when located in a basement.
• Know what type of shutoff valve you have and which direction to
turn off the valve. In most cases, counter-clockwise is the off position.
Ball Valve
Gate Valve
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FIRE EXTINGUISHERS
USE
You and your staff should practice the motion of operating a fire extinguisher. Do not
pull the pin or squeeze the lever during a practice; this will break the extinguisher seal
and cause it to lose pressure.
To operate an extinguisher remember PASS (Pull – Aim – Squeeze – Sweep)
1. Pull the pin.
2. Aim the nozzle or hose at the base of the fire from the recommended safe
distance.
3. Squeeze the operating lever to discharge the fire-extinguishing agent.
4. Sweep the nozzle or hose from side to side until the fire is out. Move forward
or around the fire area as the fire diminishes. Watch the area in case of
reignition.
MAINTENANCE
Monthly Maintenance: Every 30 days you should verify the following:
1. Is the extinguisher in the correct location?
2. Is it visible and accessible?
3. Does the gauge or pressure indicator show the correct pressure?
Annual Maintenance: Your fire extinguisher needs annual maintenance, which may
require professional service. Each fire extinguisher is different so you will need to read
the manual or instructions on your fire extinguishers for specific instructions.
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EVACUATION ROUTES

Evacuation route maps have been posted in each work area. The following
information is marked on evacuation maps:
1. Emergency exits
2. Primary and secondary evacuation routes
3. Locations of fire extinguishers
4. Fire alarm pull stations’ location
a. Assembly points


Site personnel should know at least two evacuation routes.
Remember to not evacuate residents to a place where the emerg vehicles
will be pulling up, running hoses etc
EMERGENCY PHONE NUMBERS
FIRE DEPARTMENT: _ (____) ____________
PARAMEDICS: _ (____) ___________
AMBULANCE: _ (____) __________
POLICE: _ (____) ____________
FEDERAL PROTECTIVE SERVICE :_(___) ___________
SECURITY (If applicable): _ (____) _____________
BUILDING MANAGER (If applicable): _ (___) __________
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UTILITY COMPANY EMERGENCY CONTACTS
(Specify name of the company, phone number and point of contact)
ELECTRIC: _____________________
WATER: _______________________
GAS (if applicable): __________________________
TELEPHONE COMPANY: _______________________
Date: ___/____/_____
EMERGENCY REPORTING AND EVACUATION PROCEDURES
Types of emergencies to be reported by site personnel are:
• MEDICAL
• FIRE
• SEVERE WEATHER
• BOMB THREAT
• CHEMICAL SPILL
• STRUCTURE CLIMBING/DESCENDING
• EXTENDED POWER LOSS
• OTHER (specify)___________________________________(e.g., terrorist
attack/hostage taking)
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MEDICAL EMERGENCY
Call medical emergency phone number (check applicable):
� Paramedics
� Ambulance
� Fire Department
� Other
Provide the following information:
a. Nature of medical emergency,
b. Location of the emergency (address, building, room number), and
c. Your name and phone number from which you are calling.
• Do not move victim unless absolutely necessary.
• Call the following personnel trained in CPR and First Aid to provide the required
assistance prior to the arrival of the professional medical help:
Name:_________________________
Phone:_______________________
Name:_________________________
Phone: ________________________
• If personnel trained in First Aid are not available, as a minimum, attempt to provide the
following assistance:
1. Stop the bleeding with firm pressure on the wounds (note: avoid contact with blood or
other bodily fluids).
2. Clear the air passages using the Heimlich Maneuver in case of choking.
• In case of rendering assistance to personnel exposed to hazardous materials, consult
the Material Safety Data Sheet (MSDS) and wear the appropriate personal protective
equipment. Attempt first aid ONLY if trained and qualified.
Date___/___/___
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FIRE EMERGENCY
When fire is discovered:
• Activate the nearest fire alarm (if installed)
• Notify the local Fire Department by calling .
• If the fire alarm is not available, notify the site personnel about the fire emergency by
the following means (check applicable):
� Voice Communication
� Phone Paging
� Radio
� Other (specify)
Fight the fire ONLY if:
• The Fire Department has been notified.
• The fire is small and is not spreading to other areas.
• Escaping the area is possible by backing up to the nearest exit.
• The fire extinguisher is in working condition and personnel are trained to use it.
Upon being notified about the fire emergency, occupants must:
• Leave the building using the designated escape routes.
• Assemble in the designated area (specify location):
• Remain outside until the competent authority (Designated Official or designee)
announces that it is safe to reenter.
Designated Official, Emergency Coordinator or supervisors must (underline one):
• Disconnect utilities and equipment unless doing so jeopardizes his/her safety.
• Coordinate an orderly evacuation of personnel.
• Perform an accurate head count of personnel reported to the designated area.
• Determine a rescue method to locate missing personnel.
• Provide the Fire Department personnel with the necessary information about the
facility.
• Perform assessment and coordinate weather forecast office emergency closing
procedures
Area/Floor Monitors must:
• Ensure that all employees have evacuated the area/floor.
• Report any problems to the Emergency Coordinator at the assembly area.
Assistants to Physically Challenged should:
• Assist all physically challenged employees in emergency evacuation.
Date___/___/___
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EXTENDED POWER LOSS
In the event of extended power loss to a facility certain precautionary measures should
be taken depending on the geographical location and environment of the facility:




Unnecessary electrical equipment and appliances should be turned off in the
event that power restoration would surge causing damage to electronics and
effecting sensitive equipment.
Facilities with freezing temperatures should turn off and drain the following lines
in the event of a long term power loss.
o Fire sprinkler system
o Standpipes
o Potable water lines
o Toilets
Add propylene-glycol to drains to prevent traps from freezing
Equipment that contain fluids that may freeze due to long term exposure to
freezing temperatures should be moved to heated areas, drained of liquids, or
provided with auxiliary heat sources.
Upon Restoration of heat and power:
 Electronic equipment should be brought up to ambient temperatures before
energizing to prevent condensate from forming on circuitry.
 Fire and potable water piping should be checked for leaks from freeze damage
after the heat has been restored to the facility and water turned back on.
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CHEMICAL SPILL
The following are the locations of:
Spill Containment and Security Equipment: ___________________________
Personal Protective Equipment (PPE):
MSDS:_____________________________________________________
When a Large Chemical Spill has occurred:
 Immediately notify the designated official and Emergency Coordinator.
 Contain the spill with available equipment (e.g., pads, booms, absorbent powder,
etc.).
 Secure the area and alert other site personnel.
 Do not attempt to clean the spill unless trained to do so.
 Attend to injured personnel and call the medical emergency number, if required.
 Call a local spill cleanup company or the Fire Department (if arrangement has
been made) to perform a large chemical (e.g., mercury) spill cleanup.
Name of Spill Cleanup Company:_______________________________
Phone Number:_____________________________________________

Evacuate building as necessary
When a Small Chemical Spill has occurred:
 Notify the Emergency Coordinator and/or supervisor (select one).
 If toxic fumes are present, secure the area (with caution tapes or cones) to
 prevent other personnel from entering.
 Deal with the spill in accordance with the instructions described in the
 MSDS.
 Small spills must be handled in a safe manner, while wearing the proper
 PPE.
 Review the general spill cleanup procedures.
Date___/___/___
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STRUCTURE CLIMBING/
DESCENDING EMERGENCIES
List structures maintained by site personnel (tower, river gauge, etc.):
No.
Structure Type
Location (address, if
applicable)
Emergency Response
Organization* (if available
within 30-minute response
time)
Emergency Response Organization(s):
Name _______________________________ Phone ________________________
Name _______________________________ Phone ________________________
(Attach Emergency Response Agreement if available)
* - N/A. If no Emergency Response Organization available within 30-minute response
time additional personnel trained in rescue operations and equipped with rescue kit
must accompany the climber(s).
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TELEPHONE BOMB THREAT CHECKLIST
INSTRUCTIONS: BE CALM, BE COURTEOUS. LISTEN. DO NOT INTERRUPT THE CALLER.
YOUR NAME: __________________________ TIME: _____________ DATE: ________________
CALLER'S IDENTITY SEX: Male _____ Female ____ Adult ____ Juvenile ____ APPROX. AGE: _____
ORIGIN OF CALL: Local __________ Long Distance ___________ Telephone Booth __________
VOICE
CHARACTERISTICS
___ Loud
___ High Pitch
___ Raspy
___ Intoxicated
___ Soft
___ Deep
___ Pleasant
___Other
____________
SPEECH
___ Fast
___ Distinct
___ Stutter
___ Slurred
___ Slow
___ Distorted
___ Nasal
____________
LANGUAGE
___ Excellent
___ Fair
___ Foul
___ Good
___ Poor
___Other __________
MANNER
___ Calm
___ Rational
___ Coherent
___ Deliberate
___ Righteous
___ Angry
___ Irrational
___ Incoherent
___ Emotional
___ Laughing
ACCENT
___ Local
___ Foreign
___ Race
___ Not Local
___ Region
BACKGROUND NOISE
___ Factory
___ Machines
___ Music
___ Office
___ Machines
___ Street
___ Traffic
___ Trains
___ Animals
___ Quiet
___ Voices
___ Airplanes
___ Party
___ Atmosphere
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BOMB FACTS
PRETEND DIFFICULTY HEARING - KEEP CALLER TALKING - IF CALLER SEEMS
AGREEABLE TO FURTHER CONVERSATION, ASK QUESTIONS LIKE:

When will it go off? Certain Hour _____ Time Remaining

Where is it located? Building area?

What kind of bomb? ___________________

What kind of package?______________

How do you know so much about the bomb?_____________________

What is your name and address?_________________________________


If building is occupied, inform caller that detonation could cause injury or death.
Activate malicious call trace: Hang up phone and do not answer another line.
Choose same line and dial *57 (if your phone system has this capability). Listen
for the confirmation announcement and hang up.

Call Security at _________________ and relay information about call.

Did the caller appear familiar with plant or building (by his/her description of the
bomb location)? ________________________________________________

Write out the message in its entirety and any other comments on a separate
sheet of paper and attach to this checklist.

Notify your supervisor immediately.
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SEVERE WEATHER AND NATURAL DISASTERS
Tornado:
• When a warning is issued by sirens or other means, seek inside shelter.
Consider the following:
- Small interior rooms on the lowest floor and without windows,
- Hallways on the lowest floor away from doors and windows, and
- Rooms constructed with reinforced concrete, brick, or block with no
windows.
• Stay away from outside walls and windows.
• Use arms to protect head and neck.
• Remain sheltered until the tornado threat is announced to be over.
Earthquake:
• Stay calm and await instructions from the Emergency Coordinator or the
designated official.
• Keep away from overhead fixtures, windows, filing cabinets, & electrical power.
• Assist people with disabilities in finding a safe place.
• Evacuate as instructed by the Emergency Coordinator and/or the designated
official.
Flood:
If indoors:
• Be ready to evacuate as directed by the Emergency Coordinator and/or the
designated official.
• Follow the recommended primary or secondary evacuation routes.
If outdoors:
• Climb to high ground and stay there.
• Avoid walking or driving through flood water.
• If car stalls, abandon it immediately and climb to a higher ground.
Hurricane:
• The nature of a hurricane provides for more warning than other natural and
weather disasters. A hurricane watch issued when a hurricane becomes a threat
to a coastal area. A hurricane warning is issued when hurricane winds of 74 mph
or higher, or a combination of dangerously high water and rough seas, are
expected in the area within 24 hours.
Once a hurricane watch has been issued:
• Stay calm and await instructions from the Emergency Coordinator or the
designated official.
• Moor any boats securely, or move to a safe place if time allows.
• Continue to monitor local TV and radio stations for instructions.
• Move early out of low-lying areas or from the coast, at the request of officials.
• If you are on high ground, away from the coast and plan to stay, secure the
building, moving all loose items indoors and boarding up windows and openings.
• Collect drinking water in appropriate containers.
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Once a hurricane warning has been issued:
• Be ready to evacuate as directed by the Emergency Coordinator and/or the
designated official.
• Leave areas that might be affected by storm tide or stream flooding.
During a hurricane:
• Remain indoors and consider the following:
- Small interior rooms on the lowest floor and without windows,
- Hallways on the lowest floor away from doors and windows, and
- Rooms constructed with reinforced concrete, brick, or block with no
windows.
Blizzard:
If indoors:
• Stay calm and await instructions from the Emergency Coordinator or the
designated official.
• Stay indoors!
• If there is no heat:
- Close off unneeded rooms or areas.
- Stuff towels or rags in cracks under doors.
- Cover windows at night.
• Eat and drink. Food provides the body with energy and heat. Fluids prevent
dehydration.
• Wear layers of loose-fitting, light-weight, warm clothing, if available.
If outdoors:
• Find a dry shelter. Cover all exposed parts of the body.
• If shelter is not available:
- Prepare a lean-to, wind break, or snow cave for protection from the wind.
- Build a fire for heat and to attract attention. Place rocks around the fire to
absorb and reflect heat.
- Do not eat snow. It will lower your body temperature. Melt it first.
If stranded in a car or truck:
• Stay in the vehicle!
• Run the motor about ten minutes each hour. Open the windows a little for fresh
air to avoid carbon monoxide poisoning. Make sure the exhaust pipe is not
blocked.
• Make yourself visible to rescuers.
- Turn on the dome light at night when running the engine.
- Tie a colored cloth to your antenna or door.
- Raise the hood after the snow stops falling.
• Exercise to keep blood circulating and to keep warm.
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CRITICAL OPERATIONS
During some emergency situations, it will be necessary for some specially assigned
personnel to remain at the work areas to perform critical operations.
Assignments:
Work Area
Name
Job Title
Description of Assignment
______________________________________________________________________
______________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Personnel involved in critical operations may remain on the site upon the
permission of the site designated official or Emergency Coordinator.

In case emergency situation will not permit any of the personnel to remain at the
facility, the designated official or other assigned personnel shall notify the
appropriate _______________ offices to initiate backups. This information can
be obtained from the Emergency Evacuation Procedures included in the
___________________ Manual.

The following offices should be contacted:
Name/Location:________________________________
Telephone Number:_____________________________
Name/Location:________________________________
Telephone Number:_____________________________
Name/Location:________________________________
Telephone Number: _____________________________
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TRAINING
The following personnel have been trained to ensure a safe and orderly
emergency evacuation of other employees:
Facility:
Name
Title
Responsibility
Date
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
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EMERGENCY PLAN CHECKLIST
(information listed is based on Regulation 61-84)
_____Yes
_____No
A written Emergency Plan that has been coordinated with the county emergency
preparedness agency and approved by the South Carolina Department of Health and
Environmental Control Division of Health Licensing Division of Emergency Preparedness.
_____Yes
_____No
All staff and volunteers are aware of and have been trained on the Emergency
Plan for our home or community.
_____Yes
_____No
A copy of the Emergency Plan is provided to each resident or resident’s sponsor
at the time of admission.
_____Yes
_____No
Precautions for visitors in the home or community at the time of an emergency
will be treated the same as for staff.
_____Yes
_____No
The Emergency Plan has a sheltering plan that includes the following, but is not
limited to:
a.
The licensed bed capacity and average occupancy rate;
b.
The name, address and phone number of the sheltering facility(ies)
to which the residents will be relocated during an emergency;
c.
A signed letter of agreement by authorized representatives of each
sheltering facility that includes: the number of relocated residents
that can be accommodated; sleeping, feeding and medication plans
for relocated residents; and provisions for staff
members/volunteers. THIS LETTER IS UPDATED ANNUALLY.
d.
We are located in one of the following counties and have a
sheltering facility outside of our county: Beaufort, Berkeley,
Charleston, Colleton, Dorchester, Horry, Jasper or Georgetown.
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_____Yes
_____No
The Emergency Plan has a transportation plan that includes agreements with
entities for relocating residents which addresses:
a.
Number and type of vehicles required and all vehicles to be used
must be have a full tank of gas at all times;
b.
How and when the vehicles are to be obtained;
c.
Who (by name of organization) will provide drivers;
d.
Procedures for providing appropriate medical support and
medications during relocation;
e.
Estimated time to accomplish the relocation and
f.
Primary and secondary routes to be taken to the sheltering
facility(ies).
_____Yes
_____No
The Emergency Plan has a staffing plan for the relocated residents to include:
a.
How can will be provided to the relocated residents, including the
number and type of staff members;
b.
Plans for relocating staff members or assuring transportation to the
sheltering facility(ies) and
c.
Co-signed statement by authorized representatives of the
sheltering facility(ies) if staffing is to be provided by the sheltering
facility.
_____Yes
_____No
The Emergency Plan has been coordinated with the following:
_____Local Emergency Preparedness Agency
_____Local Fire Department—Copy of Floor Plan with
hazardous/flammable materials sent for their information and file
_____Local Law Enforcement Agency
_____DHEC Division of Emergency Preparedness
_____Yes
_____No
The Emergency Plan
_____ Critical data sheet has been forwarded to DHEC Division of
Emergency Preparedness
_____ Updated copy has been forward to DHEC Division of Emergency
Preparedness
_____Yes
_____No
All staff and all volunteers have participated in a drill of the emergency procedures.
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EMERGENCY INFORMATION REQUIRED
1.
Name and title of individual making call
2.
Brief description of type of emergency—fire, resident fall, heart attack, etc.
3.
Telephone number you are calling from; Mobile phone suggested in case of
power outage or disruption of regular phone service.
4.
Exact location of Emergency:
o
o
o
o
Home or Community Name
Street Address
Identifying landmarks—signs, stores, etc. to help find home or community
Apartment number, building, cottage, room in building, etc.
5.
Name of Resident (if it is a medical emergency involving resident)
6.
Layout of home or community provided to fire department, police department
and others who may be involved in an emergency situation that are unfamiliar
with your home or community
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EVACUATION FROM FACILITY
1.
Notify the Administrator or the designee immediately
2.
Notify the County Disaster Preparedness Director (911)
3.
Designated “Command Post” (meeting area) is located at (fill in location away
from facility and away from danger)
4.
Designated Special Needs Shelters (if indicated) outside County are: (be sure to
have letters of agreement on file with the facilities who you are working with to provide
emergency shelter in case of an emergency) This is particularly important for facilities
located in the Coastal region on South Carolina that at least one of the facilities is
located outside of a Coastal county.
5.
Call all staff as indicated.
6.
Collect emergency items as noted on next page.
7.
Gather residents (in a pre-determined safe location) and if possible, notify
families/responsible parties of type of emergency.
8.
Ensure transportation is available (staff transporting residents using facility
vehicles or personal vehicles or contracted transportation on the way) and ensure staff
is available to assist with caring for residents at emergency shelter. Be sure vehicles to
transport residents always have a full tank of gas in case of emergency evacuation.
9.
Be sure to have a transportation plan, including agreements with entities for
relocating residents, that addresses: number and type of vehicles required; how and
when the vehicles are to be obtained; who (name of entity) will provide drivers;
procedures for providing appropriate medical support and medications during relocation;
estimated time to accomplish the relocation; primary and secondary routes to be taken
to the sheltering facility.
10.
Be sure to have a staffing plan for the relocated residents to include: how care
will be provided to relocated residents, including number and type of staff members;
plans for relocating staff members or assuring transportation to the sheltering facility;
co-signed statement by an authorized representative of the sheltering facility if staffing
is to be provided by the sheltering facility. Have a backup plan in place of
staff/volunteers from the community in case regular staff is unable to get to the home or
community due to an emergency.
11.
Ensure Maintenance Department is available or you can turn off all identified
utilities: Natural gas, Water, Electrical
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TORNADO WATCH
A “Tornado Watch” means that there are conditions highly favorable for a tornado to occur, but that a
tornado has not actually been sighted.
1.
Call County Control to verify highly suspected tornado weather
conditions.
2.
Monitor the Severe-Weather Alert-7 Channel Weather Radio.
3.
Move all residents into an area with no glass.
1.
Shut all doors entering into resident’s living quarters.
2.
Have each resident comfortably seated in an area where everyone is together and away from
glass and danger.
6.
Instruct residents as to proper procedure that will be followed in case a Tornado Warning goes
into effect.
7.
Prepare for a possible “Evacuation from Facility”.
8.
Staff must remain with residents at all times while on the alert for a
Tornado Warning.
TORNADO WARNING
A “Tornado Warning” means that a tornado has been sighted within ten miles of the facility. The following
actions must take place immediately:
1.
Move all residents as quickly, but as calmly, as possible with a pillow in their hand to an
area away from glass or danger and be sure to keep all residents together along with
staff.
2.
Have residents and staff sit on the floor, bend over toward their knees and join their
hands behind their head if possible. Use the pillow for support and protection.
3.
Quickly close all doors in the facility.
4.
Monitor weather conditions on the Severe-Weather Alert-7 Channel Weather Radio.
5.
Staff must remain with residents until the “Tornado Warning” has been cleared or
Evacuation from the Facility takes place.
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Sample Pre-Hurricane Season Letter to Families/Responsible Parties
Date:
Dear Family Member, Guardian, or Responsible Party,
Hurricane season is upon us again, and we are sending out this letter to detail our
facility emergency preparedness plan in the event of an imminent storm. We have
worked closely with xxxx County officials and local Emergency Management to ensure
the safety and comfort of our residents and staff.
If a hurricane Category One or Two is in our path, our plan calls for (identify specifics
per facility plan). We have a safe building above flood level with shutters for all of the
windows. We have emergency supplies, food, and water to last at least one week, and
we have an emergency generator that will supply essential electrical power to the
building in case of a power outage.
If forecasters are calling for a Category _ _ _ _ _ hurricane, we will be directed by _ _ _
_ __ _ _ _ _ _ County officials to leave our building. Depending on the path of the
hurricane, we may evacuate to _ _ _ _ _ _ _ _ _ _ _ _ or to a facility in _ _ _ _ _ _ _ _ _
_ _ _ County with whom we have an arrangement. We have coordinated transportation
arrangements for our residents and all supplies will be brought with us. We will plan on
staying out of our facility for at least one week, though we may return to our facility
sooner than this. Of course, there may be the possibility of an extended stay out of the
facility depending on the aftermath of the storm. Prior to the evacuation, our staff will
make all attempts to contact you and to inform you that we will be leaving our facility. If
we are able to reach you, we will provide you with a phone number you can call for an
update.
In the case of a facility evacuation, you may prefer to pick up your loved one. We will
discharge the resident to your care with their prescribed medications, and we will
readmit them upon our return to the facility. You will be given this option when our staff
contacts you regarding the evacuation.
If you have any questions regarding our hurricane preparedness or evacuation plan,
please call me at (xxx) xxx-xxxx ext. xx. Thank you for your consideration and
cooperation in this matter.
Sincerely,
Xxx xxxx,
Administrator or Executive Director
Phone Number
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© 2012 South Carolina Association of Residential Care Homes
FIRE PLAN
In the event of a fire, the following actions are to take place immediately:
1.
Make sure the resident(s) within immediate danger are removed from
the area.
2.
Ask for assistance from all staff members.
3.
Pull fire alarm box and call 911.
4.
Use the fire extinguisher to try to fight the fire if it will not put you in
danger.
5.
Close all doors.
6.
Move all residents away from the area and safely out of the building.
7.
Take the “Monthly Roster of Residents” so staff may use to account
for residents.
8.
Help resident if on fire by having them drop and roll if possible. If this
is not possible, wrap the resident in a flame retardant blanket or cover
and smother the fire.
Precautions:
1.
Touch the door before entering the room. IF IT IS HOT, DO NOT
OPEN IT!! Wait for emergency personnel.
2.
Move residents from the area of the fire first, then move all residents
from the other areas and get everyone out of the building to the
designated “safe area”.
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HURRICANE WATCH
A “Hurricane Watch” means a hurricane may threaten, but it is not
imminent.
1.
Call County Control to verify highly suspected hurricane conditions.
2.
Monitor the Severe-Weather Alert-7 Channel Weather Radio.
3.
Move residents to a safe area.
4.
Secure the facility by closing doors and windows or installing
shutters.
5.
Have each resident comfortably seated and all together in safe area.
6.
Instruct residents as to the proper procedure that will be followed in
case a “Hurricane Warning” is issued.
7.
Prepare for Facility Evacuation. Be sure vehicles are gassed and
emergency supplies are ready—including medicines, etc. for every
resident.
8.
Staff must remain with residents at all times, being alert for a
“Hurricane Warning”.
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HURRICANE WARNING
A “Hurricane Warning” means a hurricane is expected to strike within 24
hours or less, with sustained winds of 74mph or more and dangerously
high water and waves. Voluntary and mandatory evacuations will be
announced at this time.
1.
Move residents in safe area, all together along with staff.
2.
Ensure residents are as comfortable as possible, play games, sing,
do whatever is necessary to keep everyone calm.
3.
Check to be sure all doors and windows are closed.
4.
Monitor Severe-Weather Alert-7 Weather Radio for evacuation
notification.
5.
Staff to remain with residents at all times until the Hurricane Warning
has been lifted or the Facility Evacuation takes place.
6.
Contact Emergency Shelters to advise of situation and ensure they
are ready.
7.
Once the evacuation notice is ordered, leave immediately. Avoid
flooded roads, crowded evacuation routes and watch out for washedout bridges.
8.
Secure the facility—turn off utilities and take your emergency items
with you.
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EARTHQUAKE PLAN
While there are few earthquakes in South Carolina, we are on a fault and
facilities should be prepared just in case.
1.
Staff is to have residents do one of the following:
o go to the doorway of their room and sit on a chair or stand
o get on the floor under a table
2.
The Maintenance Department or you shall be responsible for
checking any possible natural gas or water leaks, and for checking
the building structures for damage before any residents or staff are
allowed to return inside the facility.
After an earthquake has passed, there are expected aftershocks. The
following procedures should be followed:
1.
Move the residents to a safe location that has been identified by the
staff as not being involved with the earthquake.
2.
Assess any damage to the building and determine if Facility
Evacuation is needed.
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© 2012 South Carolina Association of Residential Care Homes
MISSING RESIDENT
In the event one of the residents in the facility wanders away from the
building and/or grounds of the facility, the following procedure is to be
implemented:
1.
Immediately notify the Local Police and Sheriff’s Department (911)
and the Administrator and/or designee.
2.
Give the Police and Sheriff’s Department a full description of the
resident including the clothing the resident was last seen wearing—
give a picture of resident if available.
3.
Notify the resident’s family or responsible party immediately and
notify DHEC within 10 days of the incident.
4.
Staff should remain with other residents during the search for the
missing resident. For any staff that may be assisting with the search
for the missing resident, safety gear such as reflective vests and
flashlights should be used.
5.
Once the resident has been located, the resident must be assessed
as to his/her level of care and appropriate actions taken.
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NEWS MEDIA—RELEASE OF INFORMATION
1.
The Administrator and/or designee shall be the only individuals
allowed to communicate and release information to the news media
concerning issues, events, disasters, emergencies, or other
significant information relating to the facility and/or its residents.
2.
All members of the news media must present proper identification.
3.
Staff members are not allowed to discuss or release information to
any members of the news media. If information is released by a
staff member, this will be considered a “Breach of Confidentiality”
and appropriate disciplinary actions will be taken.
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STATE OF SOUTH CAROLINA
DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
EMERGENCY ORDER
WHEREAS, hospitals, nursing homes, and other residential care facilities subject to regulation pursuant
to SC Code Ann. §44-7-20 et seq. and regulations promulgated pursuant thereto are required to prepare
and maintain Emergency Evacuation Plans; and
WHEREAS healthcare facility plans must make adequate provisions for:
(1) Coordinating with sheltering facilities that will receive patients from evacuation areas, so that
sheltering facilities named in evacuation plans are aware of that designation and prepared to
receive additional patients;
(2) Demonstrating the capability for transporting residents and patients to sheltering facilities;
(3) Planning for relocating staff or providing staff at the sheltering facilities;
WHEREAS there is a substantial potential that one or more hurricanes will threaten the South Carolina
coast during a hurricane season; and
WHEREAS the identified deficiencies in facility evacuation plans must be corrected promptly;
NOW THEREFORE,
IT IS ORDERED, pursuant to SC Code Ann. §44-1-140 that, in addition to the requirements of
Regulation 61-16, Standards for Licensing Hospitals and Institutional General Infirmaries, Section 207;
Regulation 61-17, Standards for Licensing Nursing homes, Section B.8.; Regulation 61-84, Standards for
Licensing Community Residential Care Facilities, Section 1401; Regulation 61-13, Standards for
Licensing Habilitation Centers for the Mentally Retarded or Persons with Related Conditions, Section
B. (8); and Regulation 61-103, Standards for Licensing Residential Treatment Facilities for Children and
Adolescents, Section J.6.a.; Regulation 61-78, Standards for Licensing Hospices, Section 1701; and
Regulation 61-93, Standards for Licensing Facilities that Treat Individuals for Psychoactive Substance
Abuse or Dependence, Section 1502, each facility subject to one or more of the foregoing regulations
shall prepare an Emergency Evacuation Plan that conforms to the following requirements:
(1) (a) A Sheltering Plan for an alternate location to house patients or residents. This Plan
shall include: full provision for at least the number of licensed resident or patients beds at
that facility; the name, address and phone number of the Sheltering Facility (or Facilities)
to which the patients or residents will be relocated during an emergency; a Letter of
Agreement signed by an authorized representative of each Sheltering Facility which must
Include: the number of relocated patients or residents that can be accommodated;
sleeping, feeding and medication plans for the relocated patients or residents; and
provisions for accommodating relocated staff. The Letter of Agreement must be updated
annually and whenever significant changes occur. For those facilities located in
Beaufort, Charleston, Colleton, Horry, Jasper and Georgetown Counties, at least one
Sheltering Facility must be located in a county other than the six named counties.
(b) In the event a hospital or nursing home is located in an area subject to an order of
evacuation and current data from the Army Corps of Engineers indicates the facility will
not be affected by the storm surge, the following information must be current and on file
with the Department before the facility can be considered for exemption from the mandatory
evacuation order:
(i) A Critical Data Sheet must be complete and on file with the Department of
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Health and Environmental Control which certifies the following:
- Emergency power supply is available for a minimum of 72 hours;
- A 72 hour medical supply is available on site;
- A 72 hour supply of food and water is on site.
The Critical Data Sheet website for entering information is located at
http://scangis.dhec.sc.gov/cdatasheet/login.aspx
(ii) Adequate staff must be available and on duty to provide continual care for
the residents
(iii) An engineer’s report concerning the wind load the facility should withstand
must be on file with the Department;
(iv) The facility must request an exemption from the evacuation order from
DHEC’s Health Licensing Division.
(2) A Transportation Plan for relocating the patients or residents. The Transportation Plan
must include the number and type of vehicles required; how and when they will be
obtained; who (by name or organization) will provide drivers; procedures for providing
medical support and medications during relocation; the estimated time to accomplish the
relocation; and the primary and secondary route to be taken to the sheltering Facility.
(3) A Staffing Plan for the relocated patients or residents. The Staffing Plan must outline in
detail how care will be provided to the relocated patients or residents, including the
number and type of staff. If staffing will be provided by the Sheltering Facility, the
Staffing Plan must be co-signed by an authorized representative of the Sheltering
Facility. If staffing will be provided by the relocating facility, plans for relocating staff
or assuring transportation to the Sheltering Facility (Facilities) must be provided.
IT IS FURTHER ORDERED that each facility shall communicate and coordinate with local Emergency
Preparedness Divisions in the development and implementation of the Emergency Evacuation Plans.
IT IS FURTHER ORDERED each facility shall certify to DHEC no later than June 1 of each year that
the Emergency Evacuation Plan contains a Sheltering Plan, Transportation Plan, and Staffing Plan
complying with the terms of this Order, and shall submit to DHEC the name(s) of the Sheltering Facility
(Facilities). A copy of this Order shall be provided to each facility.
AND IT IS SO ORDERED.
C. Earl Hunter, Commissioner
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© 2012 South Carolina Association of Residential Care Homes
August 31, 2011
MEMORANDUM
TO: Administrators of Habilitation Centers for the Intellectually Disabled or Persons with Related
Conditions
Administrators of Hospitals and Institutional General Infirmaries
Administrators of Nursing Homes
Administrators of Hospice Facilities
Administrators of Community Residential Care Facilities
Administrators of Residential Treatment Centers for Children & Adolescents
Administrators of Facilities that Treat Individuals for Psychoactive Substance Abuse or Dependence
FROM: Gwen C. Thompson
Acting Director, Division of Health Licensing
SUBJECT: Emergency Evacuation Plan Submission Requirements
NOTE: This memorandum replaces the memorandum dated January 15, 2008. Amendments were made
to comply with Act No. 47 of 2011.
Each facility is required to submit a current emergency evacuation plan (EEP) annually to the Division of
Health licensing prior to the expiration date of its license. A current EEP is one that has been developed,
revised, and/or reviewed by the facility within 120 days prior to the license expiration date. Plans should
be received in our office no later than 60 days prior to the expiration date of your license to insure that
your license is renewed in a timely manner.
For the licensing period of June 1, 2007 through May 31, 2008 all facilities will be required to submit a
copy (facilities located in Beaufort, Charleston, Colleton, Horry, Jasper and Georgetown counties will be
required to provide two copies) of their current EEP at the time of license renewal. During this one-year
period the Emergency Evacuation Plan Statement option will not be an acceptable alternative to
submission of the EEP. The Department is seeking to assure that we have an updated, current copy of
each facility’s EEP. From that point forward, the Emergency Evacuation Plan Statement option will be
accepted provided no substantial change to the EEP has been made. A facility license will not be issued
or renewed, until such time as the Division receives an acceptable completed evacuation plan that
adequately addresses all of the requirements as outlined in the Emergency Order issued by the
Department on August 30, 2004, or (after May 31, 2008) a completed Emergency Evacuation Plan
Statement certifying that the Emergency Evacuation Plan has been reviewed and no substantial changes
have been made. In addition, the plan must meet the licensing standards pertaining to
emergency/disaster preparedness contained in the DHEC regulation appropriate to the type of license
issued to your facility by the Department and are as follows:
Reg. 61-13, Habilitation Centers for the Intellectually Disabled or Persons with Related Conditions, § B.
(8).
Page 2
Reg. 61-16, Hospitals and Institutional General Infirmaries, § 207.
Reg. 61-17, Nursing Homes, § B (8).
Reg. 61-78, Hospices, § 1701.
Reg. 61-84, Community Residential Care Facilities, § 1400.
Reg. 61-103, Residential Treatment Facilities for Children and Adolescents, § J (6) (a).
Reg. 61-93, Facilities that Treat Individuals for Psychoactive Substance Abuse or Dependence, § 1502.
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The table on the next page contains all of the components from the emergency order and the regulations
that must be addressed in your EEP and in your facility procedures. Please ensure that your plan
contains all items listed and submit it to:
DHEC- Division of Health Licensing
2600 Bull Street
Columbia, SC 29201
Communication and coordination with your county emergency preparedness division is required,
however, these divisions often have their own mandates and their own responsibilities to fulfill. The level
of participation these divisions should have in your EEP is one of review, coordination, and comment. All
emergency responders should work together in an organized effort to mitigate against, prepare for,
respond to, and recover from an emergency. An acceptable form of documentation of county emergency
preparedness division review and/or coordination would be a letter from the division stating that the
facility EEP has been reviewed by the division. In lieu of this preferred documentation, a copy of
correspondence requesting that your county emergency preparedness division review and participate in
the development of your EEP will be acceptable.
After initial review and coordination with the county emergency preparedness division of your EEP,
annual review by and coordination with the county emergency preparedness division is not required.
However, when emergency evacuation plans undergo significant changes they must again be reviewed
by and coordinated with the county emergency preparedness division.
*Elements of particular interest to local emergency preparedness divisions.
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EMERGENCY EVACUATION PLAN STATEMENT
Division of Health Licensing
The Emergency Evacuation Plan Statement (EEPS) is an optional method facilities can use to assure the Department
of Health & Environmental Control (DHEC) that the Emergency Evacuation Plan (EEP) we have on file for your
facility is current.
The statement must be submitted with the licensing renewal packet and received in our office within thirty (30) days
of the expiration date of the license in order for your license to be renewed in a timely manner.
PLEASE NOTE: If any information in your Emergency Evacuation Plan on file with Department has changed e.g.,
sheltering plan, sleeping plan, feeding plan, medication plan, transportation plan, staffing plan, number of beds,
licensee, facility name, or physical address change, a new plan reflecting those changes must be submitted to our
office no later than sixty (60) days prior to the expiration date of your license. However, if only minor changes to
the EEP have occurred, you can attach those documents to this EEP Statement in lieu of sending the entire plan.
Facility Name: _______________________________________________________________________
Facility Address: ____________________________________________________________________
License Number: _________________________________
I, __________________________________________________________________
(Print Name)
acknowledge, that the Emergency Evacuation Plan (EEP) for the above named facility that is on file with the South
Carolina Department of Health and Environmental Control (DHEC) is still current and, that all contracts and/or
agreements for sheltering, sleeping, feeding, medication, transportation, and staffing contained within the plan have
been reviewed, renewed and are still in effect. If only minor changes to the EEP have occurred, I have attached
those documents to this statement for placement with our EEP on file with your office. I further attest, if required by
regulation, that our EEP has had an annual rehearsal and have documented the rehearsal to include the time, date,
summary of actions and recommendations as well as the name of the participants and, that a copy of this document
is on file and available to your Department upon request. I further attest that I have the authority, or have been
granted the authority by the licensee, to sign this document and bind the facility to the Emergency Evacuation Plan
requirements and the plan currently on file with the Division of Health Licensing.
___________________________________________________________________________________
(Signature)*
(Title)
* An acceptable signature would be that of the administrator of the facility, the owner (if licensee is a sole
proprietor), at least one officer of a corporation, an officer/partner/interest owner in a limited liability company, at
least one partner in a partnership, or the head of a governmental department (or his designated signature authority)
having jurisdiction over a facility.
Subscribed and sworn to before me this ______ day of___________________
(Month) (Year)
NOTARY SEAL
(If Out-of-State )
_________________________________________________________
NOTARY PUBLIC
My commission expires _______________________
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Please mail the statement to the South Carolina Department of Health and Environmental Control, Division of
Health Licensing, 2600 Bull Street, Columbia, South Carolina, 29201. Should you have any questions or concerns,
please contact our office at (803) 545-4370.
INSTRUCTIONS
INSTRUCTIONS
EMERGENCY EVACUATION PLAN STATEMENT
DIVISION OF HEALTH LICENSING
PURPOSE: To offer inpatient facilities an optional method to assure the Department of Health & Environmental
Control (DHEC) that the Emergency Evacuation Plan (EEP) our office has on file is current. The form is designed
to eliminate facilities having to submit a plan and from Division staff having to review a plan that has not changed
since the last submission.
EXPLANATION: The Emergency Evacuation Plan Statement (EEPS) is an optional method facilities can use to
assure the Department of Health & Environmental Control (DHEC) that the Emergency Evacuation Plan (EEP) we
have on file for your facility is current. (For further explanation, see paragraphs 1, 2, & 3 on page one.)
Item by Item Instructions:
1)
Read paragraphs 1, 2, and 3 to see if facility qualifies to use this form.
2)
Facility Name: Enter the name of the facility as it appears on the face of the license issued by the Division
of Health Licensing.
3)
Facility Address: Enter the complete facility address for where the facility is physically located.
4)
License Number: Enter the license number as it appears on the face of the license issued by the Division of
Health Licensing. (License number is located in the bottom left area of the license.)
5)
Print the name of the person that will be signing the document. (See step 6 below for the appropriate names
that should appear on this line.
6)
Verifying Signature - Ultimately, the licensee to whom the license has been issued is responsible for
ensuring the person signing this certificate is authorized to do so. An acceptable verification signature
would be one that is the administrator of the facility, the owner, (if licensee is a sole proprietor), at least one
officer of a corporation, an officer/partner/interest owner in a limited liability company, at least one partner
in a partnership, or the head of a governmental department (or his designated signature authority) having
jurisdiction over a facility.
7)
If the license application is being notarized outside of the State of South Carolina, the notary seal of that
state in which it is notarized must be affixed to the application. Otherwise, if a notary registered with the
State of South Carolina notarizes the application, the notary seal does not have to be affixed to the
application.
OFFICE MECHANICS AND FILING:
The original shall be placed in the master file of the activity in the
Division of Health Licensing and maintained there in accordance with the most restrictive retention schedule
assigned to this document or other documents contained in the file. The most restrictive retention schedule in the
master files is SBH-F&S-17, which requires documents to be kept for six years within Health Licensing. Records
are then shipped to a storage center for retention of not less than 24 years before destroying.
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Attachment 1: EMERGENCY CONTACT ROSTER- INTERNAL
STAFF Command Center Location:
Alternate Command Center Location:
Command Center Telephone Number(s):
Note: In the left hand margin, indicate numerical order in which these persons would be called during an
emergency.
Title
Contact Information
Administrator
Name
Work
Cell
Home
Email
Medical Director
Name
Work
Cell
Home
Email
Director of Nursing
Name
Work
Cell
Home
Email
Director of Environmental Services (housekeeping)
Name
Work
Cell
Home
Email
Maintenance Supervisor
Name
Work
Cell
Home
Email
Dietary/Food Services Director
Name
Work
Cell
Home
Email
Security Director
Name
Work
Cell
Home
Email
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Safety Director
Name
Work
Cell
Home
Email
Dir. Of Plant Maintenance
Name
Work
Cell
Home
Email
Public Information Officer
Name
Work
Cell
Home
Email
Behavioral Health Counseling
Name
Work
Cell
Home
Email
Pre-Designated Command Center Staff:
Name:
Work:
Cell:
Home:
Email:
Name:
Work:
Cell:
Home:
Email:
Name:
Work:
Cell:
Home:
Email:
Name
Work
Cell
Home
Email
Name:
Work:
Cell:
Home:
Email:
Name
Work
Cell
Home
Email
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Chain of Command - The following persons are pre-delegated, in the
following order, to be in charge (Incident Commander) of an incident:
1.
2.
3.
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Attachment 2: EXTERNAL CONTACT INFORMATION
FIRE
LAW ENFORMCEMENT
EMS
COUNTY EMERGENCY MANAGEMENT
POISON CONTROL CENTER
LOCAL HOSPITAL/EMERGENCY ROOM
DHEC OFFICE FIRE & LIFE SAFETY
DHEC OFFICE OF HEALTH LICENSING
DHEC BUREAU OF CERTIFICATION
Resident Physicians
NAME
OFFICE
CELL
PAGER
Transportation Agreement/Contract Contacts
Company Name
Contact Person
Office #
Cell
Pager
Type and # of Vehicles
Company Name
Contact Person
Office #
Cell
Pager
Type and # of Vehicles
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Regarding transportation of oxygen, see US Department of Transportation
Pipeline and Hazardous Materials Safety Administration “Guidance for the
Safe Transportation of Medical Oxygen” dated September 25, 2005,
http://www.phmsa.dot.gov/news/gstomo.pdf
Sheltering Facility Agreement/Contract Contacts
Company Name
Contact Person
Office #
Cell
Pager
Will accept this # and
Type of patients
Company Name
Contact Person
Office #
Cell
Pager
Will accept this # and
type of patients
Company Name
Contact Person
Office #
Cell
Pager
Will accept this # and
type of patients
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Attachment 3: DISASTER FAMILY CARE PLAN
Name: ____________________________________________________________________
Department: ______________________________________________________________
Location/Shift: _____________________________________________________________
In the event of a major emergency in which I will not be able to go home and care for my family
or pets, please call the individual(s) listed below and provide them with the instructions
regarding the emergency.
Alternate Caregiver #1:
Name: ____________________________________________________
Address: ___________________________________________________
Daytime Phone: _____________________________________________
Evening Phone: _____________________________________________
Cell Phone: _________________________________________________
Alternate Caregiver #2:
Name: ____________________________________________________
Address: ___________________________________________________
Daytime Phone: _____________________________________________
Evening Phone: _____________________________________________
Cell Phone: _________________________________________________
Location of children or other dependents:
Name
School/Daycare
Facility
Telephone/Cell
Phone Numbers
Medications
Allergies
Other pertinent information:
______________________________________________________________________________
Signature
Date
See also www.scdhec.net (Hurricane Preparedness; Terrorism & Disaster Preparedness), www.scemd.org
(Prepare for a Disaster), www.redcross.org (Get Prepared) for guidance.
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Attachment 4: NOTIFICATION PROCEDURES CHECKLISTS
Procedures must be developed in order for your facility to receive timely information on
impending disasters or potential disasters, and notification of key staff and patients of
emergency conditions.
PREPAREDNESS: Notification Plan
Plans should be in place that:
Date/Time Completed
Initials
Item
Indicate person(s) at your facility responsible for disseminating
internal warnings.
Indicate modes of internal warning (intercom, alarm system,
group page)
Describe modes for receiving external warnings (NOAA
weather radio, TV, etc.)
Explain how key staff will be alerted.
Explain how patients/residents will be alerted and
precautionary measures to be taken.
Identify procedures for notifying those areas or facilities to which
patients will be moved or relocated.
Identify procedures for notifying families that patients have been
moved or relocated.
Describe alternate warning system(s) in the event primary mode
fails.
RESPONSE: Communications Procedures
Note: All calls should be routed through the Command Center.
Date/Time
Completed
Initials
Item
Alert staff, patients/residents and visitors of emergency
Call off-duty staff from emergency call-down roster.
County emergency
management agency notified, if applicable.
Local fire department notified, if applicable
Resident physicians notified, if applicable
SCDHEC Division of Health Licensing notified, if applicable.
Families notified, if applicable.
Advise host shelter sites of estimated time of departure and arrival, and
numbers and medical condition of patients.
Advise SCDHEC Division of Health Licensing via telephone and fax of
departure and destination, & numbers and medical condition of patients.
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Attachment 5: EVACUATION CHECKLISTS
PREPAREDNESS: Items potentially needed for evacuation
Ramp to load residents on buses
First aid kit(s)
Medication Administration Records (MAR) - entire chart if possible
Special legal forms, such as signed treatment authorization forms, do not resuscitate
orders, and advance directives
Resident contract agreements
Clothing with each resident’s name on their bag
Water supply for trip- staff and residents (one gallon/resident/day)
Emergency drug kit
Non-prescription medications
Prescription medications and dosages (labeled), to include physician order sheet
Communications devices: cell phones, walkie-talkies (to communicate among vehicles), 2
way radios, pager, Blackberry, satellite phone, laptop computer for instant messaging, CB
radio (bring all you have)
Air mattresses or other bedding (blankets, sheets, pillows)
Facility checkbook, credit cards, pre-paid phone cards
Cash, including quarters for vending machines, laundry machines, etc
Important papers: insurance policies, titles to land and vehicles, etc.
List of important phone numbers
Emergency prep box: trash bags, baggies, yarn, batteries, flashlights, duct tape, string,
wire, knife, hammer and nails, pliers, screwdrivers, fix-a-flat, jumper cables, portable tire
inflator, tarps, batteries, etc.
Non perishable food items- staff and residents
Disposable plates, utensils, cups, straws
Diet cards
Rain ponchos
Battery operated weather radio and extra batteries, to include hearing aid batteries and
diabetic pump batteries
Hand sanitizer
Incontinence products
Personal wipes
Toiletry items (comb, brush, shampoo, soap, toothpaste, toothbrush, lotion, mouthwash,
deodorant, shaving cream, razors, tissues)
Denture holders/cleansers
Toilet paper
Towels
Latex gloves
Plastic bags
Bleach/sterilizing cleaner
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Coolers
Lighters
Mops/buckets
Extension cords
Office supplies, such as markers, pens, pencils, tape, scissors, stapler, note pads, etc.
Laptop computer with charger; Flash drives or CDs with medical records
Maps, to include evacuation routes
Hurricane tracking chart
Sunscreen/sunglasses
Insect Repellant
Tarps and Rope
Vehicle Emergency Kit (Safety Triangles, road flares, engine oil, transmission fluid,
funnels, jumper cables, tow rope or chain, tool kit, etc.)
RESPONSE: PRIOR TO EVACUATION
Date/Time
Initials Item
Completed
Determination made of number of patients that must be
transported by ambulance, van, car, bus or other method
Transport services contacted and necessary transportation
arranged.
Receiving facilities contacted and arrangements made for receipt
of patients.
Contact made with facility’s medical director and/or the
patient’s physician
Necessary staff contacted for assistance in transporting patients
and caring for patients at the receiving facility.
County Emergency Management Agency contacted and informed
of the status of the evacuation.
Roster made of where each patient will be transferred and notify
next of kin when possible.
Patients readied for transfer, with the most critical patients to
be transferred first. Include:
a. change of clothes
b. 3 day supply of medications
c. 3 day supply of medical supplies
d. patient’s medical chart to include next of kin
e. patient identification, such as a picture, wrist
band, identification tag, or other identifying document to
ensure patients are not misidentified
Adequate planning considerations given to special needs
patients, such as dialysis patients.
Adequate planning considerations given to patients on oxygen.
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Determination made of number of patients that must be
transported by ambulance, van, car, bus or other method
Transport services contacted and necessary transportation
arranged.
Receiving facilities contacted and arrangements made for receipt
of patients.
Contact made with facility’s medical director and/or the
patient’s physician
Necessary staff contacted for assistance in transporting patients
and caring for patients at the receiving facility.
County Emergency Management Agency contacted and informed
of the status of the evacuation.
Roster made of where each patient will be transferred and notify
next of kin when possible.
Attachment 6: RESPONSE- EXTENDED CARE FACILITY RESIDENT CENSUS AND
CONDITIONS TO BE USED FOR DISASTER EVACUATION PLANNING AND
REPORTING
Facility Name
Contact Person(s)
Phone #, pager #, etc.
License Number
Address
Medicare #
Medicaid #
Total Residence Census
Please categorize your residents according to the criteria listed below:
Clients with special need(s) who are
acutely ill.
• Intravenous therapies
• Tracheotomy/respiratory care
• Stage III and IV decubitus
• Kidney dialysis
• Other _____________________
___________________________
___________________________
___________________________
___________________________
Total
Clients with special need(s), but
whose condition will probably
deteriorate during an evacuation.
• Intravenous therapies
• Tracheotomy/respiratory care
• Stage III and IV decubitus
• Kidney dialysis
• Other _____________________
___________________________
___________________________
___________________________
Total
Clients with limited needs.
• Bladder/bowel incontinence
• Chairbound
• Tube feeding
• Indwelling catheter
• Contractures
• Injections
• Other _____________________
___________________________
___________________________
___________________________
Total
______________________________________________________________________________
Signature of Person Completing Form
Date
Title
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Attachment 7: SHELTER-IN-PLACE CHECKLISTS
Note: Assumption is made that your facility has permission from authorities to shelter-inplace, or your facility has been directed to shelter-in-place due to the nature of the disaster.
Also note this checklist is not disaster-specific, so all items will not necessarily be
applicable, depending on the nature of the disaster.
PREPAREDNESS
Date Completed
Initials
Item
Plan in place describing how three days of non-perishable
meals are kept on hand for patients, residents, and staff. The
Plan should include special diet requirements.
Plan in place describing how 72 hours of potable water is
stored and available to patients, residents, and staff.
Plan in place identifying 72 hours of necessary medications that
are stored at the facility and how necessary temperature control
and security requirements will be met.
Plan in place to identify staff that will care for the residents or
patients during the event and any transportation requirements
that the staff might need and how the facility will meet those
needs.
Plan in place for an alternative power source to the facility
such as an onsite generator and describe how 72 hours of fuel
will be maintained and stored.
Alternate power source plan provides for necessary testing of
the generator as required by DHEC Division of Health
Licensing regulations.
Plan in place describing how the facility will dispose of or store
waste and biological waste until normal waste removal is
restored.
Plan in place for distributing Emergency Placards to appropriate
staff
Emergency Communications Plan in place, such as for cell
phones, walkie-talkies, 2 way radios, pager, Blackberry,
satellite phone,
laptop
computer forgiven
instant
messaging,
Adequate
planning
considerations
to special
needs
HAM radio
patients,
such as dialysis patients.
Adequate planning considerations given to patients on oxygen.
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Supply and Equipment Checklist:
Item
Emergency Placards
Non perishable food items- staff and residents
Disposable plates, utensils, cups and straws
Battery operated weather radio and extra batteries
Hand sanitizer
Hurricane tracking chart
Drinking water (one gallon per day per person)
Ice
Backup generators
Diesel fuel to supply generators for power and for cooling systems
Backup supply of gasoline so staff can get to and from work
Extra means for refrigeration
Food (staff and residents)
Medicines
Medical supplies
Medical equipment (oxygen tanks)
Battery operated weather radio, flashlights and battery operated lights
Extra batteries, to include hearing aid batteries and diabetic pump batteries
Toiletry items for staff and patients/residents (comb, brush, shampoo, soap,
toothpaste, toothbrush, lotion, mouthwash, deodorant, shaving cream, razors,
tissues)
Hand sanitizer
Plywood to board up large windows, but leave space to see outside to know what
is happening
Incontinence products
Personal wipes
Denture holders/cleansers
Toilet paper
Towels
Latex gloves
Plastic bags
Bleach/sterilizing cleaner
Plastic sheeting for covering broken windows
Duct tape
Hammers
Nails
Coolers
Lighters
Mops/buckets
Extension cords
Office supplies, such as markers, pens, pencils, tape, scissors, stapler, note pads,
etc.
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Laptop computer with charger; Flash drives or CDs with medical records
Backup generators
Diesel fuel to supply generators for power and for cooling systems
Backup supply of gasoline so staff can get to and from work
RESPONSE- Note that some actions are dependent upon nature of the disaster such as
hurricane vs. a hazardous material spill in the vicinity of your facility.
Date/Time
Completed
Initials
Item
Condition of patients/residents being monitored continuously,
particularly those with respiratory problems, and provide oxygen
or suitable assistance.
Windows and exterior doors are closed
Air intake vents and units in bathrooms, kitchen, laundry, and
other rooms closed
Heating, cooling, and ventilation systems that take in outside air,
both central and individual room units turned off. (Units that only
re-circulate inside air may have to be kept running during very
cold or very hot weather to avoid harm to patients/residents)
Food, water, and medications covered and protected from airborne
contamination and from contact with waste materials, including
infectious
waste.
Contact
with
fire authorities regarding the hazard and internal
conditions.
Contact public health authorities for advice regarding the need for
decontamination and the means for doing it.
Standby vehicles with pre-filled fuel tanks stationed on the highest
point of ground nearby.
Trained staff available who can remain at the facility for at least
72 hours, especially to manage non-ambulatory residents or others
with special needs.
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Attachment 8: RECOVERY CHECKLISTS
Date
Completed
Initials
Item
Recovery operations coordinated with county emergency
management agency.
Recovery operations coordinated with local jurisdictions/agencies
to restore normal operations.
Recovery operations coordinated with authorities to perform
search and rescue.
Recovery operations coordinated with applicable jurisdiction to
reestablish essential services.
Crisis counseling for provided residents/families as needed.
Local and state authorities provided with a master list of
displaced, injured or deceased patients/residents.
Next-of-kin notified of displaced, injured or deceased
patients/residents.
Insurance agent contacted.
Hazard evaluation conducted prior to re-entry, to include potential
structural damage and items that can affect staff, volunteers,
patients and appropriate personnel.
Inventory taken of damaged goods.
Protective measures taken for undamaged property, supplies and
equipment.
Access- safe access and egress assured for staff, deliveries, and
ambulances.
Building declared safe for occupancy by appropriate regulatory
agency.
Building- Fire-fighting services available.
Building- Pest control/containment procedures in effect.
Building- Adequate environmental control systems in place.
Internal communication system functional and adequate.
Internal Communications- Emergency call system functional and
adequate.
Internal Communications- Fire alarms system(s) functional and
adequate.
Internal Communications- Notifications made to staff regarding
status of communication system(s).
External Communications- functional to call for assistance (to
fire, police, etc.).
External Communications- Notifications made to staff regarding
status of communication system(s).
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Electrical Systems- emergency generators, backup batteries and
fuel available where needed. Transfer switches in working order.
Sufficient fuel available for generators.
Equipment & supplies located in flooded or damaged areasapproved or not approved for reuse.
Equipment & supplies- including oxygen- adequate available
onsite.
Equipment & supplies- plan in place to replenish.
Equipment & supplies- equipment inspected and cleared prior to
patient use.
Equipment & supplies- ability to maintain patient care equipment
that is in use.
Equipment & supplies-flashlights and batteries (including radio
and ventilator batteries) available.
Facilities/Engineering- Cooling Plant operational.
Facilities/Engineering-Heating Plant operational.
Facilities/Engineering- Distribution System (ductwork, piping,
valves and controls, filtration, etc) operational.
Facilities/Engineering- Treatment Chemicals (Water treatment,
boiler treatment) operational.
Infection Control- Procedures in place to prevent, identify, and
contain infections and communicable diseases.
Infection Control-Procedures and mechanisms in place to isolate
and prevent contamination from unused portions of facility.
Infection Control- adequate staff and resources to maintain a
sanitary environment.
Infection Control- process in place to segregate discarded,
contaminated supplies, medications, etc. prior to reopening of
facility.
Information Technology /Medical Records – systems or backup
systems in place.
Management- adequate management staff available
Personnel- adequate types and numbers available.
Security- adequate staff available.
Security- adequate systems available.
Waste Management- System in place for trash handling.
Waste Management- System in place for handling hazardous and
medical waste.
Water systems- potable water for drinking, bathing, dietary
service, patient services.
Water systems- sewer system adequate.
Water systems- available and operational for fire suppression .
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Recovery: Re-opening the Facility
Date
Completed
Initials
Item
Repairs and maintenance complete
Emergency exits, fire extinguishers, carbon monoxide detectors,
smoke alarms and other critical systems are working
Back-up generator working
Air conditioning/heat working
Adequate, rested staff available
Counselors available to staff and residents
Adequate medical, clinical, personal care, food and water , and
building supplies delivered and available
Residents’ families notified of re-opening
Local authorities (police and fire) notified
State authorities (DHEC) notified
Check to see if other services in community are up and running
such as local hospital and pharmacy
Adequate medical, clinical, personal care, food and water , and
building supplies delivered and available
Residents’ families notified of re-opening
Local authorities (police and fire) notified
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NATURAL DISTASTER CHECKLISTS
Attachment 9: HURRICANE PREPAREDNESS AND EVACUATION CHECKLISTS
PREPAREDNESS: Beginning of Hurricane Season
Date
Completed
Initials
Items
Contract transportation vendors to ensure MOAs are current
Contract sheltering to ensure MOAs are current
Inventory, inspect & replenish emergency supplies
Ensure staff has copy of emergency procedures
Conduct training class on emergency evacuation and sheltering in
place procedures
Rotate emergency food stocks
Inspect air conditioning roof tie down system
Inspect facility-owned transport vehicles- change transmission fluid
and oil
Conduct vehicle safety check, to include tow bars, gas cans, spare tire
and jack inspect and replenish first aid kits and emergency medical
Inventory,
supplies to
be taken on
evacuation
Confirm
evacuation
plans
for pets
Confirm emergency radio is in working order
Confirm flashlights and extra batteries are available
Ensure adequate potable water is available
If large capacity vehicles will be used for transportation, identify
and assign staff to monitor activities and respond to problems
RESPONSE: When a hurricane is projected to impact your area: 48 Hours Before
Landfall
Date/Time
Completed
Initials
Items
Participate in conference calls with SC DHEC and your nursing
home association
Contact corporate office re: potential evacuation
Contact emergency contact for each resident re: potential
evacuation
Contact emergency vendors: Transportation provider
Contact emergency vendors: Labor provider for loading and
unloading patients
Contact emergency vendors: Medical suppliers
Contact emergency vendors: Water suppliers
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Contact emergency vendors: Food suppliers
Contact transfer facilities
Determine emergency work schedule
Test answering machine
Check communications equipment: phones, walkie talkies, radios,
etc.
Verify routes to transfer facilities
Conduct safety check of vehicles, emergency equipment, vehicle
kits
Inventory vehicle emergency supplies
Test backup generators (such as for freezers, refrigerators)
Test batteries in emergency lights and exit signs
Ensure applicable workers have emergency placards
Inspect storage areas and ensure all items are up off the floor and
covered with plastic
Inventory all medications, first aid kits and other medical supplies
& replenish as needed
Order emergency supplies of medications
RESPONSE: When a hurricane is projected to impact your area and a voluntary or
mandatory evacuation is imminent
Date/Time
Completed
Initials
Items
Participate in conference calls with SC DHEC and your nursing home
association
Confirm emergency work schedule
Announce possible move to residents
Fully charge batteries for communication equipment; ensure extra
batteries are available
Ensure each vehicle to be used has list of phone #s in
order to communicate with other staff/vehicles
Ensure each vehicle to be used has routes to sheltering facility
Withdraw emergency cash
Review emergency rules for vehicle evacuation
Gather and/or secure loose exterior items
Pack resident charts in plastic storage boxes
Pack 2 weeks of medications for each evacuating resident
Fill vehicle fuel tanks
Move pets to designated facility
Review Attachment 9: Extended Care Facility Resident Census and
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Conditions to be Used for Disaster Evacuation Planning and
Reporting
Update and issue ID bracelets
Order emergency medical supplies
Order emergency water supply
Order emergency food supply
Contact transportation providers and confirm arrangements
RESPONSE: Hurricane Evacuation Ordered
Date/Time
Completed
Initials
Items
Participate in conference calls with SC DHEC, your nursing
home association, and the County Emergency Preparedness
Division
Activate telephone answering machine
Contact corporate office re: evacuation
Post emergency phone #s on front door
Notify police, fire, county emergency preparedness, etc. of decision
to leave
Inform insurance agent
Prepare bag lunches, water, drinks for traveling staff and residents, as
applicable
Unplug and cover computers
Create backup computer files for administration to take with them
Shut down water heaters and elevators
Shut down power to all buildings
Shut off gas
Lock all doors and gates
Pack vehicles
Pack resident and staff personal items in labeled plastic bags (pillow,
blankets, towels, clothes, etc.)
Pack important documents
Pack other items such as hearing aids, dentures, eyeglasses, walkers
and canes
Pack medications
RESPONSE: Shelter-in-Place- See Attachment 7, Shelter-in-Place Checklists
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ATTACHMENT 10: CHECKLISTS FOR OTHER NATURAL DISASTERS
A. RESPONSE: SEVERE THUNDERSTORMS
Date/Time
Completed
Initials
Item
NOAA weather radio on alert to receive statements, watches or
warnings issued by the National Weather Service
Relocate to inner areas of building as possible
Keep away from glass windows, doors, skylights and
appliances.
Refrain from using phones, taking showers
B. RESPONSE: TORNADO
Note that most tornados occur between 3 and 9 pm and peak tornado occurrence in the
southern states is March through May. The average tornado lasts 8-10 seconds.
a. All staff need to know the difference between a Tornado Watch (conditions are favorable
for the development of a tornado) and Tornado Warning (a tornado has been sighted or
indicated by radar).
b. Remain calm and in protective posture until declared safe by public authorities.
c. Assess injuries and damages suffered by patients/residents, the facility, and utilities as
soon as the tornado danger has passed. Compile injury and damage reports at the
command post.
TORNADO WATCH
Date/Time
Completed
Initials
Item
NOAA weather radio on alert to receive statements, watches
or warnings issued by the National Weather Service
Residents and assigned staff inside facility and accounted for
Local radio and/or television station on to receive continuous
weather information
Outdoors and indoors checked for any objects that could
become projectiles in high winds (outdoors- lawn furniture, grills,
potted plants, rakes, tools, etc.; indoors- drinking glasses, metal
trays, etc.)
Windows and exterior doors tightly closed
Supply of flashlights and extra batteries readily available.
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TORNADO WARNING
Date/Time
Completed
Initials
Item
NOAA weather radio on alert to receive statements, watches
or warnings issued by the National Weather Service
Patients/residents moved to central hall away from windows
(other potential areas-basement, first floor interior hallways,
restrooms or other enclosed small areas)
Restrooms or vacant rooms checked for visitors or stranded
residents and escort to shelter area.
Doors t o p a t i e n t /resident r o o m s s h u t a f t e r r e s i d e n t s
a r e removed.
Mattresses and/or blankets provided to patients/residents to
reduce injury from flying debris.
Staff and ambulatory patients/residents instructed to take
position of greatest safety: crouch down on knees with head
down and hands locked at back of neck or protect head/body
with pillows or mattress.
Electricity, water and fuel lines shut off, if time permits.
C. FLOODING
PREPAREDNESS: FLOODING
Date
Completed
Initials
Item
NOAA weather radio on alert to receive statements, watches
or warnings issued by the National Weather Service
Staff trained regarding definition a flood WATCH (flash
flooding is possible in your area)
Staff trained regarding what to do during a flood WATCH
(be alert to signs of flash flooding and be ready to evacuate on
a moment’s notice)
Staff trained regarding definition of a flood WARNING (a
flash flood is occurring or will occur very soon)
Staff trained regarding what to do during a flood WARNING
(listen to local radio or TV station for information and
advice. If told to evacuate, do so as soon as possible.)
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RESPONSE: FLOODING
Date/Time
Completed
Initials
Item
NOAA weather radio on alert to receive statements, watches
or warnings issued by the National Weather Service and TV
station is on for listening to information and advice
Shut off water main to prevent contamination
Move records to a higher floor or area.
WATCH- fill vehicle gas tanks in the event an evacuation is
ordered
C. RESPONSE: WINTER STORMS
Date/Time
Completed
Initials
Item
NOAA weather radio on alert to receive statements, watches
or warnings issued by the National Weather Service
Secure facility against frozen pipes
Check emergency and alternate utility sources
Check emergency generator
Conserve utilities – maintain low temperatures, consistent
with health needs
Equip vehicles with chains and snow tires, if appropriate.
Ensure a 72 hour supply of food, water, medical supplies,
medicine and fuel.
Note: There are also Flash Flood Watches (flooding is expected to occur within 6 hours
after heavy rains have ended) and Flash Flood Warnings (flooding will occur within 6
hours or is occurring). Dam breaks and very heavy rain in a short period of time can lead
to flash flooding.
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ATTACHMENT 11: TECHOLOGICAL DISASTER CHECKLISTS
A. PREPAREDNESS: FIRE SAFETY
Date
Completed
Initials
Item
Employees trained on use of fire response plan
Employees trained on how to report a fire.
Employees trained on use of the fire alarm system.
Employees trained on location and use of fire-fighting
equipment.
Employees trained on methods of fire containment.
Employees trained on their specific responsibilities, tasks, or
duties.
All training documented.
Fire d r i l l s c o n d u c t e d a n d d o c u m e n t e d a s p e r
r e g u l a t o r y requirements.
Location of fire alarms posted.
Location of fire extinguishers posted.
Employees trained on use of extinguishers.
Directions posted on how to utilize emergency equipment
Employees trained on use of RACE
R: Rescue – Rescue/remove patients/residents from the
immediate fire scene/room. Stay calm- do not panic.
A: Alert – Alert local fire personnel by activating nearest
fire alarm pull station
C: Confine/Contain – Confine fire and smoke by closing all
doors and windows in the area. Crawl low if exit route is
blocked by smoke.
E: Extinguish or Evacuate – Utilize fire extinguisher as
situation permits- to extinguish small fires or escape from
large fire by spraying in a sweeping motion. Evacuate the
building immediately.
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B. BOMB THREAT
PREPAREDNESS- Procedures to be established prior to receipt of bomb threat:
Date
Completed
Initials
Procedure
Designated facility Building/Floor Wardens:
Contact name:
Telephone:
Cell phone:
Pager:
Staff trained and training documented on use of bomb threat
procedures
Bomb threat assembly area established in the event of building
evacuation
Procedures established with local law enforcement
Procedures coordinated with county emergency management
Procedures coordinated with SC DHEC Division of Health
Licensing
Procedures include emergency contact numbers
Procedures attached to checklist
Procedures posted next to each telephone
RESPONSE- Upon receipt of a bomb threat:
• Remain calm- do not hang up.
• Take notes as you talk/listen.
• Following the call, immediately call the designated Building Warden (or your
supervisor if the Building Warden is not available).
• Do not discuss the call with anyone else but the Building Warden or your supervisor.
Date of call: ________
Time of call: _______
Ask the caller:
1. Where is the bomb? ________________________________________________________
2. What time is the bomb going to explode? _______________________
3. What does the bomb look like?_______________________________________________
4. What kind of bomb is it?____________________________________________________
5. Why did you place the bomb? _______________________________________________
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Wording of the threat:
Caller information
Caller’s identity (M, F) _____________________________________________________
Tone of voice (soft, deep, high pitch, other) _____________________________________
Accent (local, foreign, regional) _______________________________________________
Speech (stutter, slurred, nasal, other) __________________________________________
Language (good, foul) _______________________________________________________
Manner (calm, angry, laughing, other) _________________________________________
Age (younger, older) _________________________________________________________
Background noises (office/factory ______________________________________________
Machines, trains, animals, airplanes, music, traffic, other ___________________________
____________________________________________________________________________
If you must evacuate the building:
•
•
•
•
•
•
•
Get out quickly
Proceed to your assembly area for head count
Do not get in your car and leave
Do not activate the fire alarm
Take your keys, purse, etc. with you
Leave all doors open
Remain in your assembly area until the “all clear” is given by the Building
Warden
________________________________________________________________________
Signature
Date
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C. PREPAREDNESS: UTILITY OUTAGES
Date
Completed
Initials
Item
Emergency radio available
Ensure a three day supply of food and water for patients and
staff
Ensure a 48 hour supply of emergency fuel.
Arrange for private contact to serve as an added back-up
resource.
Work with the county emergency management agency in
establishing a back-up resource.
Keep an accurate blueprint of all utility lines and pipes
associated with the facility and grounds.
Develop procedures for emergency utility shutdown.
List all day and evening phone numbers of emergency
reporting and repair services of all serving utility companies:
List names and numbers of maintenance personnel for day
and evening notification:
RESPONSE – Electric Power Failure
Date/Time
Completed
Initials
Item
Call NUMBER (power company)
Notify the maintenance staff.
Keep refrigerated food and medicine storage units closed to retard
spoilage.
Turn off power at main control point if short is suspected.
Evacuate the building if danger of fire.
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RESPONSE – Gas Line Break
Date/Time
Completed
Initials
Item
Notify maintenance staff, Administrator, local public
utility department, gas company and police and fire
departments.
Shut off the main valve.
Open windows.
Evacuate the building immediately. Follow evacuation
procedures
RESPONSE – Water Main Break
Date/Time
Completed
Initials
Item
Call
NUMBER_
(facility maintenance).
Shut off valve at primary control point.
Relocate articles which may be damaged by water
Call
NUMBER
(designated assistance
groups) if flooding occurs.
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Attachment 12: CHECKLISTS FOR OTHER DISASTERS
a. Missing Patient/Resident: Response
Date/Time
Completed
Initials
Item
Communicate internal notification of missing resident.
Search every room in facility.
Search immediate grounds – supply flashlights, at night
Call 911 to alert fire department/local law enforcement.
Notify responsible family member:
• Inform family that patient is missing.
• State that 911 and fire department search teams have been
notified.
• Ask family members to remain at home near a phone.
• Discourage f a m i l y m e m b e r s f r o m c o m i n g t o t h e
facility at this time.
Upon arrival of the search team, transfer authority to team
members.
Supply patient’s picture, if available, from medical r e c o r d s to
search team members.
b. Pandemic Influenza
Planning for pandemic influenza is critical for ensuring a sustainable healthcare response. The
Department of Healthand Human Services (HHS) and the Centers for Disease Control and Prevention
(CDC) have developed this checklist tohelp long-term care and other residential facilities assess and
improve their preparedness for responding to pandemic influenza. Based on differences among facilities
(e.g., patient/resident characteristics, facility size, scope of services, hospital affiliation), each facility will
need to adapt this checklist to meet its unique needs and circumstances. This checklist should be used as
one tool in developing a comprehensive pandemic influenza plan. Additional information can be found at
www.pandemicflu.gov. Information from state, regional, and local health departments, emergency
management agencies/authorities, and trade organizations should be incorporated into the facility’s
pandemic influenza plan. Comprehensive pandemic influenza planning can also help facilities plan for
other emergency situations.
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PANDEMIC INFLUENZA PLANNING CHECKLIST
LONG-TERM CARE AND OTHER RESIDENTIAL FACILITIES
PANDEMIC INFLUENZA PLANNING CHECKLIST
This checklist identifies key areas for pandemic influenza planning. Long-term care and other residential
facilities can use this tool to self-assess the strengths and weaknesses of current planning efforts. Links to
websites with helpful information are provided throughout this document. However, it will be necessary
to actively obtain information from state and local resources to ensure that the facility’s plan
complements other community and regional planning efforts.
1. Structure for planning and decision making.
Completed
In-Progress
Not Started
Pandemic influenza has been incorporated into emergency management
planning and exercises for the facility.
A multidisciplinary planning committee or team1 has been created to
specifically address pandemic influenza preparedness planning.
(List committee’s or team’s name.) ______________________________
A person has been assigned responsibility for coordinating preparedness
planning, hereafter referred to as the pandemic influenza response
coordinator. (Insert name, title and contact
information.)
________________________________________________
Members of the planning committee include (as applicable to each setting)
the following: (Develop a list of committee members with the name, title, and
contact information for each personnel category checked below and attach to
this checklist.)
Q Facility administration
Q Medical director
Q Nursing administration
Q Infection control
Q Occupational health
Q Staff training and orientation
Q Engineering/maintenance services
Q Environmental (housekeeping) services
Q Dietary (food) services
Q Pharmacy services
Q Occupational/rehabilitation/physical therapy services
Q Transportation services
Q Purchasing agent
Q Facility staff representative
Q Other member(s) as appropriate (e.g., clergy, community representatives,
department heads,
resident and family representatives, risk managers, quality improvement,
direct care staff, collective
bargaining agreement union representatives)
1. An existing emergency or disaster preparedness team may be assigned this responsibility .
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FACILITY RESPONSIBILITIES AND TASKS BY DEPARTMENT:
Job Action Sheets
Customize these sheets as needed based on the type and number of staff at your facility. Note
that more than one person should be assigned management duties and staff that will be assigned
the duties must be trained on these responsibilities. You should develop Management Duties vs.
Staff Duties for each area. The managers all report to the “Incident Commander.” All duties to be
performed are disaster- specific, so some items might not be applicable to your situation.
A. Duties of Administrator authorized to function as the “Incident Commander”
Name: _______________________________________________________________________
Date: ___________________
Time Completed
Initials
Title:___________________________________________
Item
Notify staff of disaster or impending disaster.
Determine extent/type of emergency.
Activate emergency plans.
Activate emergency staffing. (Provide transportation of
emergency personnel, as needed).
Assign responsibilities (appoint staff as needed)
Ensure relevant notifications have been made (i.e., police,
fire, EMS, county emergency management).
Appoint staff as needed to handle media-related activities
(Public Information Officer), communicate with other
agencies/facilities (Liaison Officer), ensure safety of facility and
patients (Safety Officer) and persons needed that have special
technical knowledge (such as medical or hazardous materials
expertise)
Authorize operation of Command Center.
Ensure Command Center staff has needed checklists.
Ensure staffing needs are continuously evaluated.
Authorize cancellation of special activities (i.e., trips,
activities, family visits, etc.), deliveries and services
Authorize resources as needed or requested (food, water,
medications, staff, supplies, etc.)
Receive briefings from Department Heads on pending
operations.
Authorize need for additional security or to lockdown facility
Closely monitor weather reports.
Determine need for evacuation and begin procedures if
necessary based on information provided.
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Authorize arrangements for emergency transportation of patients
Authorize activation of additional staffing.
Authorize preparation of facility to shelter-in-place, as
applicable.
Provide routine staff briefings.
Oversee notification of family members.
B. DIETARY/FOOD SERVICES
Name ________________________________________________________________________
Date ___________________________
Title _____________________________________
Management Duties:
Completed
Initials
Item
Oversee kitchen management.
Notify staff if there will be an evacuation.
Ensure gas appliances are turned off before departure.
Contact dietary/food service staff whom need to report to
duty.
Supervise m o v e m e n t a n d s e p a r a t i o n o f f o o d
s t o r e s t o designated area(s).
Supervise loading of food in the event of an evacuation.
Supervise closing of the kitchen.
Staff Duties as assigned by Manager
Completed
Initials
Item
Check water and food for contamination.
Check refrigeration loss if refrigerator not on emergency
power circuit.
Ensure 3-day supply of food stored for patients and staff.
Ensure availability of special patient menu requirements.
Assess needs for additional food stocks.
Assemble required food and water rations to move to
evacuation site, as necessary.
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C. HOUSEKEEPING SERVICES
Name ____________________________________________
Date______________________
Title ________________________________________________________________
Completed
Initials
Item
Brief supervisor as needed.
Ensure cleanliness of resident’s environment
Ensure provision of housekeeping supplies for three days.
Clear corridors of any obstructions such as carts,
wheelchairs, etc.
Ensure adequate cleaning supplies and toilet paper is available
Check equipment (wet/dry vacuums, etc.).
Secure facility (close windows, lower blinds, etc.)
Assist with moving residents/patients to departure areas as
needed.
Perform clean-up, sanitation and related preparations.
Ensure adequate supplies of linens, blankets, and pillows.
Check equipment (wet/dry vacuums, etc.).
Secure facility (close windows, lower blinds, etc.)
D. MAINTENANCE SERVICES
Name __________________________________________________
Date_____________
Title ___________________________________________________________
Completed
Initials
Item
Brief supervisor as needed.
Ensure communications equipment is operational and extra
batteries are available.
Check and ensure safety of surrounding areas (secure loose
outdoor equipment and furniture)
Secure exterior doors and windows.
Check/fuel emergency generator and switch to alternative
power as necessary.
Alert Department Heads of equipment supported by
emergency generator.
If pump or switch on emergency generator is controlled
electrically, install manual pump or switch.
Ensure readiness of buildings and grounds.
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Call fire department if applicable.
Conduct inventory of vehicles, tools and equipment
and report to administrative service.
Fuel vehicles.
Identify shut off valves and switches for gas, oil, water, and
electricity and post charts to inform personnel.
Identify hazardous and protective areas of facility and post
locations.
Close down/secure facility in event of evacuation.
Ensure all needed equipment is in working order.
Document and report repairs/supplies needed for the
building.
Ensure emergency lists are posted in appropriate areas.
Monitor fuel supplies and generators.
Be watchful for potential fire hazards, water leaks, water
intrusion, or blocked facility access.
Determine need for additional security.*
Ensure supplies and equipment are safe from theft.*
Identify and mitigate outdoor threats to facility. *
* If your facility does not have dedicated Security Staff- otherwise, these duties would be
assigned to Security.
E. NURSING/MEDICAL SERVICES
Name ___________________________________________________ Date________________
Title __________________________________________________________________
Completed
Initials
Item
Brief supervisor as needed.
Ensure delivery of resident medical needs.
Assess special medical situations.
Coordinate oxygen use.
Relocate endangered residents.
Ensure availability of medical supplies.
Secure patient records.
Maintain resident accountability and control.
Supervise residents and their release to relatives, when approved
Ensure proper control of arriving residents and their records.
Screen ambulatory residents to identify those eligible for
release.
Maintain master list of all residents, including their
dispositions.
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Assist with patient transportation needs.
Supervise emergency care
F. PATIENT SERVICES
Name ___________________________________________________ Date________________
Title __________________________________________________________________
Completed
Initials
Item
Brief supervisor as needed.
Notify resident families/responsible parties of disaster situation
and document this notification.
Coordinate information release with senior administrator.
Monitor telephone communication.
Answer telephones and direct questions/requests to
appropriate areas.
Order supplies as directed (Coordinate with Nursing/Medical
Services)
Cancel special activities (i.e., trips, activities, family visits, etc.),
deliveries and services
Make arrangements for emergency transportation of patients.
Contact additional staff when authorized.
Monitor and document costs associated with the incident.
Secure non-patient records.
Supervise and/or assist in clearing hallways, exits.
Coordinate movement of patients/residents.
Assist in transport of patients/residents from rooms to
departure areas.
Assist in transfer of patients/residents to transportation
vehicles.
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TRANSPORTATION CHECKLIST FOR EVACUATION PLANNING
The transportation checklist below will assist in evacuation pre-planning. Make copies of this
checklist and use a new one each year.
Date: _______________________
Enough buses and emergency vehicles available for facility use.
Contact transportation vendor annually to verify contracts. Include return
transportation in contract.
Verify feasibility of back-up transportation in the event that primary transportation
vendor does not respond as contracted.
Supply transportation in place for medical records, water, and food.
A list of supplies to be transported is in the emergency management plan.
A list of comfort supplies for traveling is in the emergency management plan and staff is
assigned and trained on gathering these (snacks, water, first aid kit, videos, magazines).
Transportation in place for staff accompanying and/or supporting residents.
Staff is assigned and trained on protocols for fueling vehicles, checking oil, tires,
etc. preceding evacuation.
Specially trained staff identified to handle and load medical oxygen for personal
use as needed.
Mutual aid agreement with a facility to receive residents is current and signed this year.
Includes discussion of the provision of extra supplies, including food, water, and
bedding for at least 3 days.
Current vendor supply contracts include delivery to receiving facility posthurricane. (as applicable)
Primary and secondary evacutation routes in emergency management plan.
Time for evacuation of all residents to a point of safety calculated this year. Use the
evacuation capability evaluations associated with facilty fire drills to assist in this
calculation. Extra time built in for traveling during an evacuation (some estimates
advise travel time be tripled in calculations).
Staff assigned and trained to convert the daily resident admission and discharge log
into a resident evacuation log.
Staff assigned and trained to do a final check on facility to ensure all residents and pets
are
out of the building before the facility is left.
Protocols include cash for bus and emergency vehicle drivers to cover unexpected needs.
Staff responsible for initiating a return and re-entry to home facility is identified and
communicated to staff and residents..
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Event Reporting
An incident is defined as: any unusual occurrence that results in potential or actual injury to a resident,
staff, visitor or property. An Incident Report should be completed to report any incident, situation, or
unusual occurrence that involves potential injury or harm to a resident, visitor or staff member. Incident
Reports should be completed for the following reasons: Resident issues: falls, elopements, resident to
resident altercations, resident to staff altercations, unexplained bruising or skin tears… Medication issues:
medication errors such as wrong resident receives the wrong drug, med not available, med not
given...Damage to property…and other items identified below. Incident Reports should be completed as
soon as possible after the incident occurs. The employee who first becomes aware of an incident should
begin the incident reporting.
The Administrator and/or nurse is to be notified by immediate phone call of all bolded items. All other
items are to be reported to the nurse and to the administrator at the earliest possible hour.
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All falls
All falls resulting in serious injury (beyond first aid) and/or hospitalization
Resident abuse, exploitation, neglect or physical altercation (staff/resident, resident/resident, or
visitor to resident)
Theft or Misappropriation Resident Funds, Property, or Medications
Weight loss or gain (plus or minus – 10 pounds over two months)
Elopement
Elopement off premises or with injury
Hospitalizations (other than scheduled surgeries or procedures)
Unexpected/Unplanned discharges from residence
Pressure ulcers or non-healing wounds
Dehydration resulting in hospitalization
Diabetic Crisis
Unexpected Death
Medication error (assistance/administration of wrong medication, failure to provide medication in
a timely manner; assistance with medication at wrong time; pharmacy error
Narcotic Control Count Errors
Suicide gestures, threats, plans , or attacks
Communicable disease outbreaks (flu, pneumonia, viral, scabies, hepatitis A, TB,)
Visitor, or resident injuries occurring as a result of property defects, staff mismanagement of
resident care, failure to provide aid in an accurate or timely manner
Requests for records, subpoenas
Call system not working, fire system and maglock malfunctions (notify Property Manager also)
Regulatory Activity, State Visits and Regulatory Notices
New order for bedrails, transfer poles, other assistive devices
Crisis Events: Natural Disaster, power outages, extreme temperatures inside the building, damage
to the building, etc.
Significant environmental issues resulting in physical plant problems with actual or potential
harm to residents
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