Disaster Preparedness Plan
Policy Name:
Disaster Preparedness Plan
Approved Date:
Section:
Disaster / Safety
Review Date:
Policy #:
Purpose:
Revised Date:
To establish protocol
POLICY
The Governing Body is responsible for the establishment and maintenance of an effective disaster preparedness
plan. The Clinical Director will act as the disaster and safety officer within the facility. This disaster preparedness
plan is established to provide an effective response to disasters or emergencies impacting the environment of care
for the care of patients, staff and other individuals who are in the facility when a major interruption event occurs.
The disaster preparedness plans are reviewed or updated annually or as necessitated by changes in staff
assignments, occupancy, or the physical arrangement of the building.
Fire safety and evacuation plans shall be available in the workplace for reference and reviewed by staff during staff
in-service training. Copies will be furnished to the fire code official for review upon request. Reference NFPA
LSC 101 Sections 20/21.7.1.1 and NFPS 99 Chapter 11.
The disaster preparedness plan will:

Designate and authorize key person(s) to be responsible for plan implementation.

Define and, as appropriate, integrate the facility’s role into community-wide emergency preparedness
efforts.

Include mitigation, preparedness, response and recovery in emergency management planning activities.

Identify specific response procedures to a variety of disasters, based on hazard vulnerability analysis.

Establish procedures to notify personnel and external authorities of emergencies when emergency
response measures are implemented.

Assign staff primary and secondary roles and responsibilities to cover all needed positions during an
emergency.

Effectively manage patient, staff and family activities, critical supplies, security, and interaction with
the public.

Establish evacuation procedures, or establish an alternate care site, when the facility environment
cannot support adequate patient care and treatment.

Provide an alternate source of essential utilities and internal and external communication systems in the
event of failure during a disaster or emergency.

Include emergency management procedures and responsibilities in staff orientation and in-service
programs.
EMERGENCY RESPONSE
This Governing Body will designate key individual(s) to authorize and assume responsibility for the
implementation of facility emergency disaster plans. The facility will notify civil authorities of the facility scope of
care and available resources. The facility is not staffed or equipped to offer emergency services, which limits our
participation in community wide disaster programs. The facility emergency management plans aim to mitigate or
minimize danger and the impact of staff, patients and visitors as well as prepare for, respond to and provide for
recovery during a potential disaster or emergency. In the event of an emergency or disaster, actual or impending,
which may affect the provision of services, (e.g., hurricane, flood, earthquake), patients and staff will be informed
and scheduled procedures will be cancelled. Plans will include triage, emergency treatment (within the scope of the
facility capabilities) and transfer of victims to the nearest emergency treatment center to address an emergency
which causes damage or injury in or near the facility.
By basing the planning of emergency management on realistic conceptual events, the plan reflects those issues or
events that are predictable for the environment the organization operates in. Thus, such conceptual planning will
focus on issues, such as severe weather typical in this locale, situations that can occur due to close proximity of
industrial or transportation complexes; or earthquake possibilities due to local seismic activity. Planning for these
events will focus on the capacity of the center to provide services during such an emergency. There is no way to
plan for all possible emergencies, but by focusing on local conceptual events and operating capacity thresholds, the
center has developed realistic plans as well as guidelines for staff to operate within those plans.
RESPONSILITY FOR DISASTER MANAGEMENT:
(Authority to Activate and Terminate the Emergency Management Plan)
The decision to activate the disaster management plan will be made by the authority designated within this plan, in
accordance with the activation criteria. The decision to terminate shall be made by the designated authority in
coordination with the declaring governmental agency.
Designated Authority Title
Name
Clinical Director
The Clinical Director will delegate staff responsibilities including but not limited to:
Assigning staff to cover all necessary positions, security (access, traffic control, and crowd control), identification
and monitoring of all personnel and others (patients, visitors) in the facility.
Interaction with the media, screening incoming telephone calls, shut down of equipment and utilities, as
appropriate, patient activities including scheduling, modification or discontinuation of services, control of patient
information and patient transportation, if needed, triage of incoming patients and recovering patients, staff/family
support activities, logistics of critical supplies (medications, disposables, food, linen and water).
NOTIFICATION, LOGISTICS AND MITIGATION
The Clinical Director will initiate notification and logistic support for the facility. Emergency response staff and
alternates will be identified and assigned specific responsibilities.
The facility maintains surveillance of impending threats by monitoring television or radio. In the event that an
imminent threat or emergency situation is identified, operations at the facility will cease and staff, patients and
visitors will be notified.
For emergencies occurring during operational hours, a plan will be activated, as necessary, for ceasing routine
operations, triage, emergency treatment, transfer of victims to the nearest emergency treatment center, and
evacuation of the facility. The current employee roster with telephone and pager numbers, when applicable will be
available for employees at home as well as in the facility. Scheduling information will be available for assigned
personnel to complete patient notification in a timely manner.
When an alarm is activated or a code is announced, emergency response staff will respond immediately with
appropriate equipment and supplies while awaiting the arrival of civil authority. If immediate evacuation is
required, staff members will initiate evacuation while awaiting arrival of civil authority.
The facility will maintain agreements with an area hospital and local ambulance service to facilitate patient transfer.
EMERGENCY POWER AND SUPPLIES
Emergency backup power will be available on a limited basis as required by code and generator size. The facility
does not provide emergency services or overnight care; therefore planning and provisions are only for short periods
of confining or sequestering emergencies. It is not feasible for the facility to stockpile supplies to support
emergency situations not within the facility scope of services due to the limited storage space. The facility
maintains only the supplies, food and water required for scheduled procedures.
EMERGENCY EVACUATION
The Clinical Director will determine the level of evacuation required for emergency management. Upon arrival at
the facility, the civil authorities will assume responsibility for evacuation decisions.
In the event of uncontained danger (e.g., smoke, fire, bomb, or other disaster), complete facility evacuation will be
conducted by the Clinical Director or the civil authority present at the scene. Evacuees will assemble in a
designated area furthest from the building.
EMERGENCY TRANSFER
Patients or victims that may require a higher level of care will be transferred to a hospital with which the facility
maintains a transfer agreement or to the nearest emergency treatment center. If the condition warrants, facility staff
may accompany patients.
RE-ENTRY
After an evacuation or a disaster that caused structural damage, the facility will be inspected by the civil authorities,
the Clinical Director, and the maintenance coordinator to determine that conditions are safe for re-entry and
resumption of operations. In the event of significant structural damage, approval also may be required from the
local or state construction offices.
The Clinical Director or civil authority in charge is responsible for authorizing re-entry into the facility and the
resumption of operations.
EDUCATION AND TRAINING
Orientation and in-service programs will be conducted to train all employees on their roles and responsibilities, and
to review the emergency disaster plan.
Disaster drills will include all employees, medical staff, and other occupants of the building. If utilization requires
more than one shift of operation, drills will be held on each shift.
Documented disaster (other than fire) drills will be held at least annually. Documentation of disaster drills includes,
but is not limited to types of emergencies, staff responsibilities in responding to an emergency, effectiveness of staff
response, adequacy of equipment and the alarm system, the needs identified, and the plan for staff training to
correct deficiencies.
CMS 416.41(c) Disaster Preparedness Plan
Standard
Interpretive Guideline
How We Met Standard
Disaster
Preparedness Plan
The intent of this regulation is for an ASC to have
in place a disaster preparedness plan to care for
patients, staff and other individuals who are on the
ASC‟s premises when a major disruptive event
occurs. The governing body of the ASC is
responsible for the development of this plan
See Disaster Preparedness Plan).
Hazard
Identification
Comprehensive emergency management includes
the following phases, which should be taken into
account in the development of the ASC’s disaster
preparedness plan:
Hazard Vulnerability (HVA) was assessed.
ASCs should make every effort to include any
potential hazards that could affect the facility
directly and indirectly for the particular area in
which it is located.
List identified potential hazards for your facility
Indirect hazards could affect the community but not
the ASC, and as a result interrupt necessary utilities,
supplies, or staffing.
Hazard Mitigation
Hazard mitigation consists of those activities taken
to eliminate or reduce the probability of the event,
or reduce the event’s severity or consequences,
either prior to or following a disaster or emergency.
Mitigation details should address provision of
needed care for the ASC’s patients being prepared
for procedures, undergoing procedures, or
recovering from procedures, as well as how the
ASC will educate staff in protecting themselves and
others present in the ASC in the event of an
emergency. Comprehensive hazard mitigation
efforts, including staff education, will aid in
reducing staffs' vulnerability to potential hazards.
These activities precede any imminent or postimpact timeframe, and are considered part of the
response.
The emergency plan should include mitigation
processes for patients, staff and others present in the
facility at the time of the disaster or emergency.
Preparedness
Preparedness includes developing a plan to address
how the ASC will meet the needs of patients, staff,
and others present in the ASC if essential services
break down as a result of a disaster. It will be the
product of a review of the basic facility information,
the hazard analysis, and an analysis of the ASC‟s
ability to continue providing care and services
during an emergency. It also includes training staff
on their role in the emergency plan, testing the plan,
and revising the plan as needed.
List P&P’s for fire, bomb etc.
Standard
Interpretive Guideline
Response
Activities taken immediately before (for an
impending threat), during and after a
disaster/emergency event to address the immediate
and short-term effects of the emergency.
Recovery
Activities and programs that are implemented
during and after the ASC‟s response that are
designed to return the ASC to its usual state or a
"new normal.
Coordination of the
Plan
The regulation requires that the ASC must
coordinate its disaster preparedness plan with State
and local authorities that have responsibility for
emergency management within the State.
Coordination should take place in addressing
threats that either extend beyond the premises of the
ASC, e.g., floods, earthquakes, or biochemical
releases, etc., or threats within the ASC that require
response from a community agency, e.g., fire
department.
How We Met Standard
List coordination/participation with local/state agencies.
The regulation does not require that ASCs be
integrated into State and local emergency
preparedness plans to address threats that extend
beyond the premises of the ASC, since it will
ultimately be the decision of the State and local
officials whether and how they might utilize ASCs
in a response to an emergency event. ASCs must,
however, document that they have made efforts to
communicate with their State and local emergency
preparedness officials to inquire about potential
coordination.
Testing, Evaluating,
and Updating the
Plan
At least once every year the ASC must conduct a
drill to test the plan’s effectiveness. A drill that is
conducted in concert with State or local authorities
would qualify as an annual test. While the drill
does not have to test the response to every
identified hazard, it is expected to test a significant
portion of the plan. For example, a fire drill does
not qualify on its own as a sufficient annual drill of
the ASC’s plan.
Disaster drills are conducted annually.
The ASC must prepare a written evaluation of each
annual drill, identifying problems that arose as well
as methods to address those problems. The disaster
preparedness plan must be promptly updated to
reflect the lessons learned from the drill and the
needed changes identified in the evaluation.
List date and type of drill
Fire safety drills are conducted quarterly.
Documentation of each drill is maintained.
An evaluation is done after all drills to identify improvement
potential.
Disruption in Service Tool
Utility
Mfg. Book on file
Contact Information
What to do in case of malfunction
Life Support Utilities
Medical Gases
□ Yes □ No
□ NA
Electricity
□ Yes □ No
□ NA
The generator will kick in. Continue with patient care.
Generator/Emergency Power
System
□ Yes □ No
□ NA
If the generator does not work, cases will be cancelled
until the system is functional.
Autoclave
□ Yes □ No
□ NA
Negative Air in each
operating room
□ Yes □ No
□ NA
HVAC
□ Yes □ No
□ NA
Filters will be changed at least quarterly and more
often if needed
Plumbing
□ Yes □ No
□ NA
Shut off water main
Water
□ Yes □ No
□ NA
Shut off water main
Fire Alarm System
□ Yes □ No
□ NA
Fire sprinkler System
□ Yes □ No
□ NA
Fire Exit Illumination
□ Yes □ No
□ NA
Telephone System
□ Yes □ No
□ NA
Paging systems Intercoms
□ Yes □ No
□ NA
Nurse call system
□ Yes □ No
□ NA
Code Blue Buttons
□ Yes □ No
□ NA
Infection Control Systems
Environmental Systems
Communication System
WATER

Notify the Clinical Director of the surgery center. Only the current case in progress will proceed, all other
cases will be cancelled until water is restored.

Notify Water Company. Telephone Number:

Restrict use of water. If possibility of contamination exists, turn off main water valve.

Deliver adequate drinking water to each designated area.

Consider the possibility of recovering and storing the water toilet tanks, water heaters and boilers.

Inform personnel to be prepared to line toilets with plastic bags for removal of human waste. Plastic bags
should then be considered infectious waste.

Water shut off valve is located at: ________________________________
____________
GAS

Notify the Clinical Director of the surgery center.

Notify Gas Company. Telephone number: _____________________________

If gas leak is evident, notify Fire Department.

Evacuate all persons and open doors and windows to ventilate.

Shut off local valve or main valve at meter.

Do not use matches, candles, or other open flame devices; activate light switches, or other electrical
appliances.

Gas shut-off is located at: _____________________________________________

To turn off gas: _________________________________________________
ELECTRICITY

Notify the Clinical Director of the surgery center. Only current cases will continue, all other will be cancel

Notify electric company for repair services. Telephone number: ______________

Main power panel is located: ____________________________.

To turn off electrical power you: _______________________________.

For long duration of electrical power outage access:
o
o
o
Medication & Food sensitive items
Test & Reprogram equipment
Monitor emergency generator load
COMMUNICATION

Notify the phone company via cell phone (a cell phone will be available at the center)

In case of emergency the cell phone is used to activate emergency services.
MEDICAL GAS

Shut off local valve or main valve on cylinder

Medical gas valve located at: ______________________________________________

To turn off: ______________________________________________________________

If the current case is done under local, the case will be continued and portable oxygen will be used.

Only local cases will be performed without medical gases

Contact Medical Gas Company. Telephone number: ______________________________

If leak noted, provide ventilation to area, consider evacuation.
HOT WATER SYSTEM

Cases will continue without the hot water system.

Notify the contracted maintenance service for repair

The surgery center is not on a sewer system. Refer to the water shut-off protocol.
Emergency Triage Telephone Call List
Name
Title
Phone #
Person for you to contact
Name
Clinical Director /
Safety Manager
Registered Nurse
Registered Nurse
Registered Nurse
OR Tech
Phone #