XYZ NURSING HOME EMERGENCY PREPAREDNESS PROGRAM INDEX
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1 XYZ NURSING HOME SAMPLE EMERGENCY PREPAREDNESS PROGRAM EMERGENCY MANAGEMENT PLAN INDEX SECTION A: POLICIES AND PLANNING Policy and Organizational Statements... Risk Assessment Process... Communications Plan... Continuity of Operations... Training and Testing Program... PLAN SECTION B: PROCEDURES APPLICABLE TO ALL HAZARD RESPONSES Activation of Plan... Communications Plan... Managing Resources and Assets during a Disaster... Managing Security and Safety during a Disaster... Management of Staff during a Disaster... Management of Utilities during a Disaster... Managing Residents during a Disaster... SECTION C: INCIDENT COMMAND SYSTEM Incident Command System Concept of Operations... Activation of the Incident Command System... Incident Command Organizational Chart... Command Center Organizational Chart
2 Job Action Sheets and Associated Forms SAMPLE Incident Commander... Documentation Recorder... Public Information Officer... Safety/Security/Liaison Officer... Planning Section Chief... Labor Pool Unit Leader... Finance Section Chief... Operations Section Chief... Nursing Supervisor / Director of Nursing / Charge Nurse / Department Director... Triage Unit Leader... Holding Area Unit Leader... SECTION D: FULL BUILDING EVACUATION PLAN Full Building Evacuation Algorithm... Introduction... Action Plan... Resident Preparation Guides... Evacuation Floor Plans... Receiving Facilities for Evacuation
3 SECTION E: EMERGENCY PROCEDURES FOR SPECIFIC EVENTS Active Shooter/Person with a Weapon... Bioterrorism / Terrorism... Bomb Threat / Suspicious Package... Carbon Monoxide Alarm Activation 1... Civil Disturbance / Demonstrations... Contamination of the Outside Air (fire, smoke, chemical, radiological 2 )... Drought 3... Earthquake... Fire... Flood (Internal & External)... Hazardous Material Spill or Leak... Hostage Taking... Hurricane 4... Landslide 5... Loss of Central Services: Loss of Air Conditioning / High Heat... Loss of Cooking Ability... Loss of Electric Service... Loss of Elevator Service... Loss of Fire Protection Systems... Loss of Heating System... Loss of Information Technology... Loss of Natural Gas / Propane 6... Loss of Oxygen / Vacuum Delete procedure if no Carbon Monoxide alarms 2 Delete reference to radiological if no nuclear facility or no major transportation route near facility Revise if propane versus natural gas 7 Delete if no piped med gases in facility 3
4 Loss of Sewer / Waste System... Loss of Steam Pressure 8... Loss of Telephone Service, Internal Communications, Nurse Call.. Loss of Water Service / Contamination of Water Supply... Missing Resident... Natural Gas 9 Odor / Propane Odor / Leak... Sand / Dust Storm Security Situation... Snow Emergency / Ice Storm Tornado / High Winds... Tsunami / Tidal Wave Volcanic Eruption Wildfire SECTION F: EMERGENCY RESOURCES AND LISTS Facility Information Detail... Emergency Contacts... Supply Delivery Location... Disaster Kit Contents... Emergency Response Agency Phone Numbers... External Response Partners Phone Numbers... Emergency Bedding Materials... Emergency Food Supply List... Emergency Transport Equipment to Move Residents... Elevator Keys... 8 Delete if no steam service in facility 9 Revise if propane versus natural gas
5 Transportation Resources Facility Owned Vehicles... UTILITY MANAGEMENT Emergency Utility Shut-Off Locations... Generator Information... Vendor Sources of Fuel... EMERGENCY CONTRACTOR / VENDOR LISTS Housekeeping / Linen Services... Food Services Department... Transportation... Maintenance Department... Restoration Companies... Nursing... Pharmacy... Respiratory Therapy... SECTION G: CONTINUITY OF OPERATIONS AND RECOVERY PLAN Recovery Plan Overview... Disaster Recovery Algorithm... Damage and Operational Assessments... Full Recovery
6 APPENDICES: 15 Appendix A: Hazard Vulnerability Analysis (HVA) Facility Specific HVA Community HVA - PLACEHOLDER Evidence of HVA Annual Analysis & Review Appendix B: Mutual Aid Agreements / Memorandum(s) of Understanding Appendix C: Compliance Schedule / Calendar Appendix D: Vendor Agreement Appendix E: Evacuation Route Maps Appendix F: Organization Chart and Roster of Staff with Key Disaster Roles Appendix G: Roster of Companies and Organizations with Key Disaster Related Roles Appendix H: Resident and Responsible Party - Emergency Communications Plan Appendix I: Staff Competencies PLACEHOLDER Appendix J: Collaborative and Cooperative Planning Efforts Documentation 15 Customize Appendices and insert into plan 6
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