Emergency Preparedness Plan Checklist for
Licensed DD 24 Hr Residential Services in Oregon
Yes/No
Licensing
Yes/No
Better practice
General
Comments
Y/N An emergency preparedness
(EP) plan has been prepared,
reviewed and updated, at least
annually and as needed. The
dates of preparation, review and
update are documented.
Y/N The plan or parts of the plan
Y/N The home/agency has made
have been practiced at least
emergency preparedness a
annually. This could be staff
regular agenda item at staff
demonstrating or running
meetings and the plan is
through actions that are part of
exercised in different ways at
the plan, such as turning off
least quarterly. Particular
natural gas, or starting the
attention is focused on
generator, if available. This
educating new staff or
could also include discussion or
replacement staff on their roles
role-playing around a theoretical
and responsibilities in an
problem, also called a tabletop
emergency.
exercise. Documentation could
be found on in-service tracking
record, personnel records,
attached to the plan or other site.
Page 1 of 18
DHS 0937 (11/09)
Emergency Preparedness Plan Checklist for
Licensed DD 24 Hr Residential Services in Oregon
Yes/No
Licensing
Y/N
Y/N The plan addresses all events
likely to happen in the area. At
a minimum, this includes
earthquake, fire and pandemic.
For areas known to experience
extreme weather, this should
include weather-caused events
(wind, floods, extreme heat and
cold). The plan should address
one type of event likely to
require sheltering in place and
one event that will require an
evacuation. For homes,
designated in the inundation
zone, this includes tsunamis.
Better practice
Y/N In the plan, there is a clear
chain of command that
assumes a manager will not
always be present or available.
Y/N The plan clearly indicates local
officials that are likely to give
directions that should be
followed.
Y/N  The plan addresses all
events that have happened
in the area in the past 50
years and those that are
reasonably a concern, given
accidents, terrorism and
various infections. For
example, if the home is near
the freeway or train tracks,
does the plan address a
chemical spill? Does the
plan address windstorms
and loss of power?
 Plan has identified each type
of disaster and has one to
two page directions for each
that tell staff what to do if
sheltering in place, or if
Yes/No
Comments
Page 2 of 18
SDS 0937 (11/09)
Emergency Preparedness Plan Checklist for
Licensed DD 24 Hr Residential Services in Oregon
Better practice
leaving/evacuating the
home.
Y/N There is a communication
Y/N There is also a designated out
plan, giving clear direction to
of area or out of state contact
staff about the people they are to
who is willing to transfer
contact in an emergency. This
messages. The instructions
includes instruction to contact
include names or titles and
the CDDP or designee.
phone numbers and email
Requested family members of
addresses, if applicable.
the occupants are on the
communication list.
Y/N There are tools for
communication for those
situations where phones and
electricity are unavailable.
 There are increased range
walkie/talkies available and
staff have been trained in
their use.
 Ham operators have been
identified and are willing to
assist.
 The agency knows the
physical location of nearest
first responder and has a
plan to hand carry needed
Yes/No
Licensing
Yes/No
Comments
Page 3 of 18
SDS 0937 (11/09)
Emergency Preparedness Plan Checklist for
Licensed DD 24 Hr Residential Services in Oregon
Yes/No
Licensing
Yes/No
Better practice
messages/requests.
Comments
Y/N The plan takes into account
the unique needs of the
occupants of the home, such as
physical positioning needs,
hearing/sight impairment, ability
to communicate or understand
directions, equipment needs or
supports needs for behavior.
The plan has been updated if
needs have significantly
changed.
Y/N Applicable parts of the plan/s are
coordinated with each applicable
employment and alternative-toemployment provider to address
the possibility of an emergency
or disaster during work hours.
This could be written
documentation/notes of
conversations or meetings with
appropriate employment/ATE
providers about their emergency
plans (e.g. do they plan that the
group home staff will come and
pick people up?)
Page 4 of 18
SDS 0937 (11/09)
Emergency Preparedness Plan Checklist for
Licensed DD 24 Hr Residential Services in Oregon
Better practice
Y/N The agency/home has
contacted first responders
and/or local Emergency
Management and informed
them of the needs of the
residents in an emergency or
disaster.
Y/N If an individual regularly
Y/N  The individual has a
accesses the community
laminated card with
independently, the individual has
emergency contact
received information about
information.
appropriate steps to take in an
 The individual has
emergency, such as emergency
information that is kept in
contact telephone numbers,
the backpack, wallet, etc.
contacting police or fire
for first responders about
personnel and other strategies to
the individual and contact
obtain assistance. This can be
information, including
documented in ISP documents
alternates if the first contact
or other individual specific
is not available, or in case
documents.
the individual becomes
unable to adequately
communicate
in an emergency.
Y/N The agency has contacted the
local health department and
discussed plans about the
Yes/No
Licensing
Yes/No
Comments
Page 5 of 18
SDS 0937 (11/09)
Emergency Preparedness Plan Checklist for
Licensed DD 24 Hr Residential Services in Oregon
Better practice
ongoing distribution of
medications, vaccines and
medical supplies during an
emergency
Y/N The home has access to cash
to purchase food and other
supplies during a disaster
when banks and ATMs are not
available.
Sheltering In Place
Y/N The home has sufficient water Y/N  The home has sufficient
to shelter in place for a minimum
water to shelter in place for
of 3 days or has a viable plan to
a minimum of 5 days
obtain the water. This includes at
onsite. This includes at
least 1 gallon of water for each
least 1 gallon of water for
person (individual + staff) and
each person (individual +
animal. More if there are unique
staff) and animal. More if
needs, such as sanitation needs,
there are unique needs.
medical equipment, temperature
 The type of fluids available
control difficulties, etc.
at least partially takes into
account individual
preferences.
 There is a plan to rotate the
supply.
 There is capacity to sanitize
water, such as backpacking
Yes/No
Licensing
Yes/No
Comments
Page 6 of 18
SDS 0937 (11/09)
Emergency Preparedness Plan Checklist for
Licensed DD 24 Hr Residential Services in Oregon
Yes/No
Licensing
Yes/No
Y/N There is sufficient food for staff
and individuals for a minimum of
3 days. If any of the food is
canned, there is a manual can
opener. There is a plan and the
necessary tools to modify
textures or diets, if needed. If
any food needs to be cooked to
be edible, there is a safe plan
and tools to prepare the food.
Y/N If any food requires refrigeration,
the plan addresses that and
other measures to keep food
safe and non-contaminated.
Y/N At all times in the month, each
individual has at least 3 days
supply of essential
medications and medical
supplies and equipment.
Y/N
Y/N There is a plan and supplies of
sanitary supplies for 3 days,
including the ability to safely
Y/N
Y/N
Better practice
supplies or bleach with
instructions to staff.
 There is sufficient food for
staff and individuals for a
minimum of 5 days.
 The type of food is
nutritionally balanced and
takes into account
individual preferences.
 There is a plan to rotate the
supply.
Comments
 At all times in the month,
each individual has at least
5 days supply of essential
medications and medical
supplies and equipment.
 There is a plan to rotate the
supply.
 There is a plan and
supplies of sanitary
supplies for 5 days,
Page 7 of 18
SDS 0937 (11/09)
Emergency Preparedness Plan Checklist for
Licensed DD 24 Hr Residential Services in Oregon
Yes/No
Licensing
contain human waste, including
incontinence supplies.
Y/N There is an identified method to
keep individuals warm and/or,
if necessary, cool in the event
of a utility outage. This may
include a plan to evacuate to a
site with a generator or other
power source. If the home plans
to use a generator or other
alternate heating source, staff
knows how to operate the
equipment and prevent carbon
monoxide poisoning.
Y/N There are working flashlights
Better practice
including the ability to
safely contain human
waste.
 The supplies include tools
to increase the comfort and
privacy of individuals during
toileting, assuming that the
bathroom may not be
available.
 There are supplies to
maintain basic hygiene
(skin care products, etc.)
and infection control.
Y/N The plan addresses not only
the usual heating and cooling
needs but also the unusual
weather extremes and has
different strategies for shortlived and extended outages.
Yes/No
Y/N
Comments
 There is a radio either hand
Page 8 of 18
SDS 0937 (11/09)
Emergency Preparedness Plan Checklist for
Licensed DD 24 Hr Residential Services in Oregon
Yes/No
Licensing
with back up batteries.
Y/N Staff have been trained in their
responsibilities in the plan and
know where the plan and
necessary supplies are located.
Y/N There are policies in place that
staff are not to leave after a shift
without adequate replacements
Y/N There is a plan to provide
ongoing staffing in the event
that some staff are unable to
work as scheduled. This may
include staff becoming live-ins,
activation of administrative or
Better practice
crank or battery powered.
 There is at least one
flashlight for each staff and
each individual who could
likely use one.
Y/N  There is at least one phone
which is not portable.
 If there is a computer in the
home, the email contact
information for the agency,
the CDDP, and the state
are clearly listed for staff.
Staffing
Y/N Staff are trained in their
responsibilities within 30 days
of hire and whenever they
move sites.
Yes/No
Comments
Y/N There is written documentation
that staff agree with the
planned duties during an
emergency, such as including
these duties in a position
description.
Page 9 of 18
SDS 0937 (11/09)
Emergency Preparedness Plan Checklist for
Licensed DD 24 Hr Residential Services in Oregon
Licensing
management staff to provide
direct service, housing families
onsite, or other solutions.
Y/N The staffing section of the
plan has been implemented in
relevant policies, procedures, job
descriptions and/or bargaining
agreements about mandatory
overtime, changes in shifts,
potential to bring dependents
and/or pets onsite or to alternate
sites, expectations in event of an
evacuation, potential use of
volunteers, etc.
Yes/No
Yes/No
Better practice
Comments
Y/N Staff have been educated and
assisted to develop their own
personal/family emergency
plan, in order that they will be
more comfortable with
continuing their position duties
during an emergency.
Y/N The agency/home has a clear
picture of which staff are likely
to have significant barriers to
either continuing their
responsibilities during an
Page 10 of 18
SDS 0937 (11/09)
Emergency Preparedness Plan Checklist for
Licensed DD 24 Hr Residential Services in Oregon
Yes/No
Licensing
Y/N There is a fire evacuation plan
that shows the emergency
egress or escape routes. There
is a designated gathering area
on the plan.
Y/N All staff have been trained in
their designated duties during
an evacuation.
Better practice
emergency or reporting for
their shift during adverse
conditions, such as which staff
have children or others who
may require care during a
school closure, or those who
may have troubles with
transportation during an ice
storm.
Evacuation
Y/N  The designated gathering
area on the plan is a place
where individuals will be
protected from the
elements.
 The plan designates
location of fire
extinguishers.
Y/N  All staff, when asked, can
name their designated
duties during an
evacuation.
 Individuals and volunteers
have duties identified, if
appropriate. Individuals and
volunteers know their duties
Yes/No
Comments
Page 11 of 18
SDS 0937 (11/09)
Emergency Preparedness Plan Checklist for
Licensed DD 24 Hr Residential Services in Oregon
Yes/No
Licensing
Y/N The plan includes evacuation of
necessary medication, medical
records and necessary
equipment and supplies to meet
live sustaining and safety needs
of the individuals. Medical
records include each person’s
current MAR and TARS, the
Summary Sheet and the
Emergency Summary Sheet (or
the information of both forms
combined into one form).
Y/N There is a method to allow
identification of all occupants by
those unknown to them. It
includes, at a minimum, their
name and either the agency or
home. This could be done with
disposable plastic ID bracelets,
laminated information on a
lanyard around their neck or
even writing in permanent
marker on the forearm.
Y/N There is a minimum of one
Better practice
during an evacuation.
Y/N  The evacuation plan
includes strategies to keep
these items dry and secure
during and immediately
after an evacuation.
 The plan includes multiple
strategies for making the
information available, such
as evacuation of the
physical copies, keeping
some records saved
electronically, either off-site
or on portable media, etc.
Y/N The chosen method of
identification is easily available
to staff in a designated
location.
Yes/No
Y/N
Comments
 There are written
Page 12 of 18
SDS 0937 (11/09)
Emergency Preparedness Plan Checklist for
Licensed DD 24 Hr Residential Services in Oregon
Yes/No
Licensing
evacuation site.
 If the planned site is a
general-use public shelter
(Red Cross has indicated
that they can not meet the
needs of someone requiring
“care”), there must be written
documentation that the local
Red Cross or other
appropriate entity can meet
the individuals’ needs in
those shelters.
 Reasonable alternatives to
naming a site would include
1) families or friends of
individuals who desire (and
are likely capable of) taking
their family members with
them; or having designated
staff plan to take certain
individuals with them.
 In order to be allowed one of
the alternatives, all 3
safeguards must be in place:
1) Those agreements with
families, friends or staff must
Yes/No
Better practice
agreements with all
planned evacuation sites.
 There are a minimum of 3
places for evacuation and
preferably additional backups. One should be within
walking distance and may
be available only for a few
hours, such as a neighbor’s
house, in order to shelter
people prior to the arrival of
transportation. Another site
should be within the
community and the third
should be outside of the
area most likely affected by
a regional disaster.
Comments
Page 13 of 18
SDS 0937 (11/09)
Emergency Preparedness Plan Checklist for
Licensed DD 24 Hr Residential Services in Oregon
Licensing
be in writing. 2) There must
be evidence of back up
plans, in case family or the
designated staff are
unavailable. 3) There must
be evidence that the ISP
team approval of this
decision.
Y/N The designated evacuation
sites can reasonably meet the
health and safety needs of all,
including any unique or unusual
needs, such as individuals who
need medical equipment, who
have pica, or who need extra
supervision in order to be safe.
Y/N There is a plan to transport all
occupants of the home and
staff. The plan clearly lists the
contact numbers for all
transportation providers not
garaged onsite.
Yes/No
Yes/No
Better practice
Comments
Y/N The plan indicates how those
needs will be communicated in
written or other format to
personnel and others
unfamiliar to the individuals,
assuming that staff may not
always be available.
Y/N
 There should be written
agreements with the
transportation provider/s.
 There is at least one
backup to the plan.
 The transportation portion
of the plan has been
coordinated across the
community so that all
providers in an area are not
Page 14 of 18
SDS 0937 (11/09)
Emergency Preparedness Plan Checklist for
Licensed DD 24 Hr Residential Services in Oregon
Yes/No
Licensing
Yes/No
Y/N
Y/N The vehicles designated for
transportation include enough
seatbelts and tie-downs, if
anyone needs transport in a
wheel chair, for all individuals
and staff.
Y/N There is a mechanism to track
the physical location of
individuals until someone else
assumes responsibility of them.
This can be directions to call a
centralized site with the current
location at periodic times, a
notebook or index cards, etc.
Better practice
counting on the same
providers.
 The transportation plan
includes provisions to
transport any service
animal, such as seeing eye
dogs, and necessary
medical equipment and
mobility devices, such as
wheel chairs.
 The transportation plan
includes pets and visitors.
Comments
Y/N There are multiple strategies
for the notification.
Page 15 of 18
SDS 0937 (11/09)
Emergency Preparedness Plan Checklist for
Licensed DD 24 Hr Residential Services in Oregon
Licensing
When family or friend assumes
responsibility for an individual,
the information must include the
name of the family member or
friend, any known contact
information and any intended
destination.
Y/N The plan includes provisions to
notify the CDDP or designee of
the physical location of all
individuals in the home.
Yes/No
Yes/No
Better practice
Comments
Y/N There are multiple strategies
for the notification.
Pandemic
Y/N The plan demonstrates
Y/N  The plan demonstrates
strategies that will be used to
multiple strategies that will
maintain safe staffing
be used to maintain safe
patterns. If the plan includes
staffing patterns.
providing day care on site, there
 The plan addresses “Social
is a designated place for children
Distancing” that may be
and a plan to meet the needs of
imposed that impacts travel,
both the children and the adults.
such as medical appointments,
access to supplies and
community inclusion. “Social
Distancing” is a plan to prevent
close social contact by closing
certain public places, etc.
Y/N The staffing section of the plan
Page 16 of 18
SDS 0937 (11/09)
Emergency Preparedness Plan Checklist for
Licensed DD 24 Hr Residential Services in Oregon
Yes/No
Licensing
Y/N The home has available a 3 day
supply of any infection control
device, such as bleach, gloves
and other barriers to the spread
of germs.
Better practice
recognizes that in a pandemic,
staffing may be markedly
decreased for months.
Y/N  The agency has contacted
the local health department
about recommended
infection control devices.
 The home has available an
extended supply of any
infection control device
recommended by the local
health department, such as
bleach, gloves, and other
barriers to the spread of
germs.
Y/N Staff have received training or
information about likely
pandemics, basics on the
transmission of the germs and
proper procedures to protect
self and others.
Y/N Employees can demonstrate
proper infection control
measures, such as frequent
hand washing, use and
disposal of gloves proper
Yes/No
Comments
Page 17 of 18
SDS 0937 (11/09)
Emergency Preparedness Plan Checklist for
Licensed DD 24 Hr Residential Services in Oregon
Yes/No
Licensing
Better practice
methods to dispose of
infectious materials.
Y/N Staff knows which
information/news resources are
likely to be credible during a
pandemic, in that rumors will
be common.
Yes/No
Comments
Page 18 of 18
SDS 0937 (11/09)