Essential Plan Elements for External Disaster Plans in California Long Term Care Facilities
Develop and implement detailed written plans and procedures to meet all potential emergencies and disasters [Code of Federal Regulations (CFR) 42 § 483.75 (m), § 483.470(h)] [Health and Safety Code (H&S) 1336.3(b)]
The external disaster plan must address those types of emergencies relevant to the facility, its geographical location and the needs of the individuals served. While it is important that a disaster plan be broad enough to address all possible hazards, you should determine what the most likely risks are for your area and give particular attention to them in your plan. Are you in a flood zone or wild fire area? Does your plan include procedures for power outages during extreme temperatures?
It is also important to address the specifics needs of the people you serve. For example, if individuals in your facility are technology or oxygen dependant, then a back up source of power for their medical equipment or oxygen supply is imperative.
Develop your plan with the advice and assistance of local emergency planning officials [California Code of Regulations (CCR) Title (T) 22 §72551 (a), §76563 (a), §76928 (a)].
Consult with your local emergency planning officials to ensure that your plan does not conflict with the city or county plan. Also city or county emergency-planning staff can help you to identify what the local disaster risks and resources are. Finally, building a cooperative relationship with the individuals who are responsible for meeting the needs of the community when disasters hit can help you both to be better prepared.
The plan must be reviewed periodically, revised as necessary, and all persons must be instructed in its requirements. [CFR 42§ 483.75 (m), § 42 483.470 (h) (2)], [T22 §72551 (c), §76563 (c), §76928 (c), §73549(c)]
The plan must be realistic, tailored to your situation, and up to date at all times. All staff must be trained to the plan and ready to carry it out at any time. New employees must be oriented to the plan and procedures at the beginning of their employment.
Practice the plan. [CFR §483.75(m), §483.470(h)(2), T22 §72551(c) (d) (e), §76563(c), (d), §76928(c) (d), §73549(d)]
The best plan is only as good as its implementation. External disaster drills are required twice a year for Skilled Nursing Facilities (SNFs) and at least annually for Intermediate Care Facilities (ICF) and Intermediate Care Facilities for the Developmentally Disabled (ICF/DD). Additionally, the facility must participate in all local and state disaster drills when asked to do so by the local or state disaster or emergency medical services agencies. Use drills not only to practice your plan, but also as a means to identify the places where training and/or equipment need to be enhanced. A written report of all drills must be generated and if concerns are identified, follow up action must be documented.
Sheltering in the Facility
The plan must provide for sources of emergency utilities and supplies, including gas, water, food and essential medical supportive material. [CCR T22 §72551 (b)(1), §76563(b)(1), §76928 (b)(1), §73549(b)(1)].
Recommendations from the American Red Cross, the Federal Emergency Management Agency, and the Center for Communicable Diseases state that individuals should plan to be self sufficient for a minimum of 72 hours in the event of a wide spread disaster. Health facilities’ external disaster plans should include provisions to independently manage the essential health, safety, and personal needs of the individuals in their care during an emergency. These provisions should include:
Alternative power for emergency lights, and essential medical equipment.
Essential medications and medical supplies such as oxygen for those who require it.
Enough food and water for residents of the facility, and for the staff who will be required to stay and care for them. You also need to plan food and water for individuals you have agreed to shelter such as staff’s family members or other facility or community members.
Systems to prepare, serve, and store food in the event of power outage, including special diets.
Systems and supplies for the use of alternative water sources including the purification of water if potable water is lost, and a method to transport water from its source to the resident care areas [CFR § 483.70(h)(1)]
Systems and supplies to maintain a minimum standard of hygiene such as hand washing and management of incontinent individuals.
The plan must include procedures for assigning and recalling staff and chart the facility’s lines of authority [CCR T22 §72551 (b)(2), §76563(b)(2) & (b)(3), §76928(b)(2)& (b)3, §73549(b)(2) & (3)].
An efficient emergency response requires that everyone is clear about what their assignment is and who is in charge. Regulations require each facility to have a chart of the lines of authority. Staff also need to know what is expected regarding “call back” or “hold overs” at work during an emergency. Communicating this expectation ahead of time allows them to prepare their family’s emergency plan accordingly. Phones, including cell phones, may not be functional during the first few hours or days following a disaster, so predetermined arrangements for staff to report to work and alternative communication plans are important. Additionally, it is important for staff have facility identification that will allow them to cross a police or fire barrier to get to the facility should the area be restricted. Ask your local emergency planning office for recommendations on the kind of ID staff should have in this kind of situation.
The plan must include procedures for the moving of patients from damaged areas of the facility to undamaged areas [CCR §72551 (b)(6), §76563(b)(5), §76928(b)(5)]
There are many situations that may require moving residents from one area of the facility to another. Procedures need to describe the safe practices for movement and housing of residents in the new area, as well as how care tasks, such as food preparation and hygiene, will be managed in an area that may not be designed for these activities.
The plan must include provisions for the conversion of useable space for immediate care of emergency admissions [72551(b)(4), 76563(b)(4), 76928(b)(4)]
Your facility may not be directly impacted by a wide spread disaster, but you may be asked to offer shelter and care to others in the event of an emergency. Provisions in your plan must address how you will manage emergency admits in an orderly manner.
Seek to enter into reciprocal or other agreements with nearby facilities and hospitals to provide temporary care in an emergency [H&S 1336.3(b)]
Most community shelters are not prepared to care for medically fragile individuals or people with special supervision needs. Experience has shown that, during an emergency, residents from health facilities do better when cared for in a “like facility” or one that provides the same level of care. Long term care facilities are encouraged to, whenever possible; seek to enter into agreements with “like facilities” to accept their residents in an evacuation emergency, and to include provisions in these agreements to send care staff, medication and essential medical supplies with the residents.
During an emergency, the receiving facility may not need to have vacant beds in order to honor these agreements. L&C may grant facilities temporary permission to exceed their licensed bed capacity and/or to house residents in areas that have not previously been approved for patient care in a justified emergency [CCR T22 §72607(a)(b), §76609(a)(b) & §76936 (a)(b), §73609(a) 7 (c)].
To obtain permission to exceed licensed capacity, contact the L&C district office administrator or their designee as soon as possible when the threat of evacuation is identified. Once L&C determines that the residents health and safety needs can be reasonably met at the receiving facility, permission will be granted. If the emergency occurs outside business hours, contact the OES Warning Center at (916) 845-8911 and ask for the DHS Duty Officer who will in turn put you in touch with L&C staff. In LA County, contact the county operator at (213) 974-1234 to reach the LA County DHS/L&C duty officer after normal business hours.
The plan must include procedures for emergency transfers of patients who can be moved to other health facilities including arrangements for safe and efficient transportation. [CCR T22 §72551(b)(6), §76563(b)(6), §76928(b)(6), §73549 (b)(7)]
You are responsible for the safe transport of your residents during an evacuation. In addition to seeking to enter into reciprocal agreements with other health facilities to provide housing and care as discussed previously, you may need to arrange for additional transportation services in the event that your facility population must leave the facility all at once.
When planning for evacuation transportation needs, providers are encouraged to evaluate the facility population to determine what kind of transportation and how many vehicles the residents will require (i.e. private car or bus, wheelchair van, ambulance). If you do not have enough vehicles to transport all your residents at once and will require outside transportation resources, it is important to plan for your transportation needs ahead of time, and to discuss these plans the emergency response coordinators in your community to ensure that they do not conflict with existing agreements or plans.
The plan must contain evacuation routes, emergency phone numbers of physicians, health facilities, and local fire and EMS as well as processes for notifying family members, guardians, the state department and ombudsman of the resident’s welfare. [H&S code 1336.3(1), CCR §72552 (b)(9), §76561(b)(9), §76928(b)(9)].
Staff must act quickly during a disaster and the information they need should be up to date and included in the facility’s plan. Alternate communication systems may be necessary if the power is out, or the land phone lines are inoperable. Some examples are cell phones, email that is not dependant on phone lines, radio and satellite phones, and Citizen’s Band or HAM radio. Remember that cordless phones will not operate if the power is out but, if the phone lines are still operable, a phone that is not cordless will work when the power goes out so it is a good ides to have one around for emergencies.
The plan must outline procedures for maintaining a record of resident movement and a method of sending all pertinent personal and medical information with them [CCR T22 §72551 (b)(8)& (10), §76563(b)(8)&(10), §76928 (b)(8)&(10), §73549(b)(9)]
In an evacuation it may be necessary to send your residents to a variety of different locations. An accurate record must be maintained of where they went and when they went. Additionally, they must be sent with a disaster “tag” that contains basic medical information including medication, diet, and acute conditions as well as personal information relevant to their care. This is especially critical for patients who cannot communicate their care needs.
The plan must address security of the facility (CCR T22 §72551(b)(11), §76563 (b)(11), §76928 (b)(11), §73549(11)].
During a disaster, you may be the only building with the “lights still on” and strangers may come to your facility for assistance. Also, relatives or curious persons come to your facility to check on loved ones. Your staff need to know how to keep unauthorized individuals out of the facility in times of disaster, and how to manage concerned family members.
The plan must address procedures for the emergency discharge of patients who can be discharge without jeopardy into the community including arrangements for their care, transportation, and a follow up inquiry within 24 hours. (CCR T22 §72551(b)(7), §76563 (b)(7), §76928 (b)(7)].
There may be residents who would be better off temporarily with a family member during an evacuation situation. The procedures for emergency discharge should be developed and described in the facility plan.
The plan must include provisions to undertake prompt medical assessment of and provide treatment to residents who may have suffered adverse health consequences to the emergency or sudden transfer [H&S Code 1336.3(3), CCR §72551 (a)(12)].
The emotional and physical impacts of a disaster and sudden relocation should not be underestimated. Medically fragile and elderly residents are particularly vulnerable. Effects sometimes take days to manifest It is the responsibility of staff to be alert and watchful for signs of disaster- related problems, and to promptly assess and treat all incoming patients from other health facilities.
The plan should include the assignment of public relations liaison duties to release information to the public [CCR T22 §72551(b)(13), §76563 (b)(12), §73549 (b)(12)] *
In an emergency, anxieties are high and accurate information is critical. Assigning an individual who is skilled in communication and prepared to deal with inquiries from the public and the media is essential in preventing the spread of misinformation. *(required for SNF, ICF and ICF/DD only)