Arizona Health Care Association
DISASTER PLANNING GUIDE
SELF-ASSESSMENT CHECKLIST
EXISTING EMERGENCY / DISASTER PLANS EVALUATION
HE FOLLOWING CHECKLIST CAN BE USED TO EVALUATE A FACILITY’S EMERGENCY/DISASTER PLANS
AND IDENTIFY OPPORTUNITIES FOR IMPROVEMENT AND ENHANCEMENT.
Facility Name:
Address:
Skilled Nursing Facility
Sub acute-Care Facilities
Intermediate-Care Facilities (ICFs)
ICFs for the Developmentally Disabled (ICF/DDs)
Type of Facility:
Institute for Mental Health (SNF/STPs)
Residential Care Facility for the Elderly (RCFE)
Adult Residential Facilities (ARFs)
Residential Care Facilities for the Chronically Ill
Social Rehabilitation Facilities
Number of Residents:
Levels of Care:
Name of Person Responsible for Plan:
YES
1. General Plan Appearance:
a. Appears to be professionally developed
b. Utilizes a consistent format throughout the document
c. Utilizes a consistent font throughout the document
d. Appear to be easy to read
e. Contained in a well labeled, sturdy binder
f. Does not include any damaged pages or sections
g. Does not include any missing pages or sections
Comments:
2. Plan Organization:
a. Includes a comprehensive Table of Contents (TOC)
b. TOC appears to be accurate
c. Uses tabs for easy reference
d. Includes definition section or glossary of terms
e. Includes “quick reference” sheets that can be easily
copied and distributed for use.
Comments:
Page 1 of 10
NO
N/A
Arizona Health Care Association
DISASTER PLANNING GUIDE
SELF-ASSESSMENT CHECKLIST
EXISTING EMERGENCY / DISASTER PLANS EVALUATION
YES
3. Administrative Elements:
a. Includes Executive Summary
b. Includes language defining the Purpose of the Plan
c. Includes language defining the Applicability and Scope of
the Plan
d. Includes language defining the Legal Authorities and
References
e. Includes Record of Approval and appropriate signatures
f. Includes Record of Annual Review and appropriate
signatures
g. Includes Record of Changes / Revisions and appropriate
signatures
h. Includes Record of Internal Distribution
i. Includes Record of External Distribution
j. Includes a comprehensive profile document citing critical
characteristics of the facility
Comments:
4. Plan Updating and Maintenance:
a. Master copy of the plan kept in a secure location
b. Copies appropriately distributed throughout facility
c. Copy(s) of plan maintained in a secure off-site location(s)
d. Copies of plan distributed to appropriate partners
e. All copies updated on at least an annual basis
f. All copies updated whenever significant operational
changes occur
g. All copies updated whenever regulatory changes occur
h. All copies updated in accordance with After Action Report
findings
Comments:
5. Emergency Planning and Management Concepts:
a. References “All Hazards” Emergency Planning and
Management
b. References use of an emergency management model like
the Nursing Home Incident Command System (NHICS)
c. References concepts promoted by the National Incident
Management System (NIMS)
d. Identifies an Incident Management Team (IMT)
Page 2 of 10
NO
N/A
Arizona Health Care Association
DISASTER PLANNING GUIDE
SELF-ASSESSMENT CHECKLIST
EXISTING EMERGENCY / DISASTER PLANS EVALUATION
YES
NO
N/A
YES
NO
N/A
5. Emergency Planning and Management Concepts (continued):
a. Is identified as an Emergency Operations Plan (EOP)
b. Defines how the EOP is activated
c. Includes organizational chart
d. Identifies and defines chain-of-command
e. Utilizes NIMS / NHICS-related terminology throughout the
plan
f. Utilizes NHICS Forms
g. Utilizes Job Action Sheets (JAS)
h. Identifies location of Nursing Home Command Center
(NHCC) and alternate location(s)
i. Defines special codes or phrases for internal broadcast for
different types of emergencies
j. Includes language on Continuity of Operations / Business
Continuity
k. Identifies essential services that must be maintained to
ensure resident safety and Continuity of Operations
l. Utilizes a NHICS Kit that includes the following items:
 IMT Chart
 IMT Vests, caps, or other identifying garments
 JAS
 Clerical Items: paper, pens, pencils, directories, etc.
 Communication devices- radios, cell phones
 Other items needed for NHICS
Comments:
6. Hazard Vulnerability Assessment (HVA):
a. Plan includes formal HVA identifying potential threats and
perils
b. HVA is updated at least annually
c. Response protocols in the plan are consistent with the
HVA
Comments:
7. Communications:
a. Identifies Modes of Communications:
Page 3 of 10
Arizona Health Care Association
DISASTER PLANNING GUIDE
SELF-ASSESSMENT CHECKLIST
EXISTING EMERGENCY / DISASTER PLANS EVALUATION
 Primary mode of internal communications
 Back-up mode of internal communications
 Primary mode of external communications
 Back-up mode of internal communications
 Formal relationship with Ham Radio Operator
 All other modes of communications
b. System to re-call staff during emergencies:
 Call / phone tree
 Computerized / Automated System
 Pre-arranged assignments for select staff to
automatically report to facility
c. Risk communication plan
Comments:
8. Release of Information:
a. Identifies those authorized to release information
b. Identifies an official spokesperson(s) and back-up
spokesperson(s)
c. Identifies system to release information to the media
d. Identifies system to release information to family
members and responsible parties
e. Identifies system to release information to regulators
Comments:
9. Updated Emergency Contact Information - Internal Resources
(Citing All Forms of Contact):
a. All contact information is updated on at least a quarterly
basis
b. All contact information is updated whenever significant
changes occur
c. All contact information is date-stamped showing the most
recent update:
 Executive Staff
 Supervisory Staff
 Line Staff and Corporate Staff
 Residents’ Family / Responsible Parties
Comments:
YES
Page 4 of 10
NO
N/A
Arizona Health Care Association
DISASTER PLANNING GUIDE
SELF-ASSESSMENT CHECKLIST
EXISTING EMERGENCY / DISASTER PLANS EVALUATION
10. Updated Emergency Contact Information - External Resources
(Citing All Forms of Contact):
a. All contact information is updated on at least an annual
basis
b. All contact information is updated whenever significant
changes occur
c. All contact information is date-stamped showing the most
recent update
d. Emergency Response Agencies:
 Fire Department / Fire Authority
 Police Department
 Sheriff’s Department
 Tribal Law Enforcement Agency
 State Police Agency- Local Contact
 Emergency Medical Services
 Public Works
 Local / County / Tribal Emergency Management
Agency
 State Emergency Management Agency
e. Utilities:
 Electric
 Natural Gas
 Propane Gas
 Public Works
 Water
 Sewer
 Telephone Service – Landlines
 Telephone Service – Cellular
 Internet Provider
f. Local Health Department
g. Local Flood Control Agency
h. State Regulators
i. Federal Regulators
j. Insurance Agent(s)
k. Insurer Claims Department(s)
l. Local Disaster Relief Agency:
 Red Cross
 Salvation Army
 Charitable Organization
Page 5 of 10
Arizona Health Care Association
DISASTER PLANNING GUIDE
SELF-ASSESSMENT CHECKLIST
EXISTING EMERGENCY / DISASTER PLANS EVALUATION
YES
NO
N/A
YES
NO
N/A
10. Updated Emergency Contact Information - External Resources
(Citing All Forms of Contact) (continued):
m. Disaster Recovery / Disaster Restoration Provider
n. Local Ombudsman
o. Coroner / Morgue Services
p. Funeral Home / Mortuaries
q. Evacuation Re-location Sites in the Immediate Area
r. Other “Like” Facilities in the Immediate Area
s. Other “Like” Facilities Outside of the Immediate Area
t. Vendors Providing Emergency Assistance:
 Emergency Generator Service Contractor
 Emergency Generator Fuel Service
 Fire Alarm System Contractor
 Fire Suppression System Contractor
 Life Safety Systems Contractor
 General Contractor
 Electrical Contractor
 Plumbing Contractor
 Board-up Services
 Food Services
 Drinking Water
 Pharmaceuticals
 Medical Supplies
 Ambulance Services
 Transportation Services
 Truck / Equipment Rental
 Portable Toilets
 Other Vendors Providing Essential Services
Comments:
11. Inventory List and location of Emergency Supplies:
Comments:
12. Inventory List and location of Emergency Equipment:
Comments:
13. Disaster Menu:
Page 6 of 10
Arizona Health Care Association
DISASTER PLANNING GUIDE
SELF-ASSESSMENT CHECKLIST
EXISTING EMERGENCY / DISASTER PLANS EVALUATION
Comments:
14. General Elements of Emergency Procedures Included in the
Plan:
a. Categorized by potential threat or peril
b. Use a consistent format
c. Are concise and easy-to-read
d. Describe specific goals and objectives
e. Job tasks are integrated with NHICS protocols
f. Floor plan/sitemap with important features
Comments:
15. Evacuation Planning:
a. Evacuation procedures are clearly defined
b. Type of evacuation identified:
 Horizontal
 Vertical
 Complete Facility Evacuation
c. Comprehensive evacuation maps /diagrams are posted
throughout the facility
d. External re-assembly locations are identified
e. Includes an identification system for residents evacuated
off-site (wristbands, triage tags, face sheets, etc.)
f. Includes an Evacuation Kit
g. Includes an Evacuation Log to track residents
h. Identifies pre-established off-site temporary evacuation
sites (auditoriums, halls, schools, churches, etc.)
i. Identifies pre-established “like” facilities for longer term
evacuation in immediate area
j. Identifies pre-established “like” facilities for longer term
evacuation outside of the immediate area
k. Primary evacuation routes identified and includes maps
and directions
l. Secondary evacuation routes identified and includes maps
and directions
m. Copies of agreements (transportation, relocation sites,
etc. ) in plan
Comments:
Page 7 of 10
Arizona Health Care Association
DISASTER PLANNING GUIDE
SELF-ASSESSMENT CHECKLIST
EXISTING EMERGENCY / DISASTER PLANS EVALUATION
YES
16. Sheltering-In-Place Planning:
a. Sheltering-in-Place procedures are clearly defined
b. Safe or “hardened” areas in the building have been
identified
c. Safe or “hardened” areas in the building have been
identified with a sign or placard
d. Includes a Sheltering-in-Place Kit
e. Includes provisions to allow staff and their family to stay
at the facility during a disaster
Comments:
17. Specific Emergency Procedures Included in the Plan:
a. Fire / Explosion
b. Emergent Severe Weather Events (storms, hurricanes,
tornados, etc.)
c. Prolonged Severe Weather Events (excessive cold,
excessive heat, etc.)
d. Earthquake
e. Heating Failure
f. Cooling Failure
g. Mechanical Failure
h. Fire Protection Systems Failure
i. Life Safety Systems Failure
j. Emergency Generator System Failure
k. Utility Failure:
 Electric
 Natural Gas
 Propane Gas
 Public Works
 Water
 Sewer
 Telephone Service – Landlines
 Telephone Service – Cellular
 Internet Provider
l. Emergency Shutdown Procedures- Utilities, Mechanical
Equipment, Technology, etc.
m. Hazardous Materials Incident- Internal (spill, leak, exposure, etc.)
n. Hazardous Materials Incident- External (spill, leak, exposure, etc.)
Page 8 of 10
NO
N/A
Arizona Health Care Association
DISASTER PLANNING GUIDE
SELF-ASSESSMENT CHECKLIST
EXISTING EMERGENCY / DISASTER PLANS EVALUATION
YES
18. Specific Emergency Procedures Included in the Plan (continued):
o. Missing Resident / Elopement
p. Bomb Threat
q. Internal / Workplace Violence
r. Security Breach
s. Facility Lockdown
t. Labor Action
u. Civil Disturbance / Riot
v. Terror Event
w. Epidemic / Pandemic / Mass Medical Emergency
x. Supply / Delivery Disruption
y. Any peril unique to the facility’s HVA
Comments:
19. Capacity to Handle Deceased Residents or Other:
a. Procedures to handle remains of those who have died
b. Temporary morgue identified
c. Morgue Log
d. Supply of Body Bags
e. PPE / Universal Precautions
Comments:
20. Post Incident Damage Assessment:
a. Defines Damage Assessment Procedure
b. Includes Damage Assessment Checklist
Comments:
21. Disaster Recovery:
a. Defines Disaster Recovery Procedures
b. Includes system to sequentially reactivate elements of the
operation
c. Includes Disaster Recovery Checklist
d. Recovery Analysis
 Identify strengths
 Vulnerabilities
 Opportunities for improvement
Comments:
Page 9 of 10
NO
N/A
Arizona Health Care Association
DISASTER PLANNING GUIDE
SELF-ASSESSMENT CHECKLIST
EXISTING EMERGENCY / DISASTER PLANS EVALUATION
YES
22. Authority to Call for Re-Entry into a Stricken Facility:
a. Defines Authority for Re-Entry
b. Describe Re-Entry Procedure
Comments:
Page 10 of 10
NO
N/A