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Spokane Regional Health District
Medical Needs Shelter Plan
Table of Contents
Section
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
Topic
Page
Purpose........................................................................................................... 3
Common Definitions ..................................................................................... 3
Laws, Authorities and Policies ..................................................................... 3
Planning Assumptions .................................................................................. 4
Defining “Special Needs” Populations ........................................................ 4
1.
Traditional/Dormitory Shelters .............................................................. 5
2.
Medical Needs Shelters.......................................................................... 5
3.
Acute Care Facilities .............................................................................. 6
Concept of Operations .................................................................................. 6
1.
Operational Lead Agency & Management ............................................ 6
2.
Pre-Activation Activities ....................................................................... 6
3.
Preparation of Special Needs Populations for Evacuation .................... 7
4.
Activation ............................................................................................... 7
5.
Facilities ................................................................................................. 7
6.
Patient Capacity ..................................................................................... 7
7.
Patient Records………………………………………………………...7
8.
Patient Tracking……………………….……………………………….8
9.
Prescriptions ........................................................................................... 8
10. Staffing................................................................................................... 9
11. Security .................................................................................................. 9
12. Transportation ...................................................................................... 10
13. Communication .................................................................................... 10
14. Set-Up .................................................................................................. 10
15. Signage ..……………………………………………………………. 10
Facility Layout ............................................................................................ 10
1.
Arrival & Entrance Area ...................................................................... 10
2.
Patient Registration/Information Area ................................................. 10
3.
Triage Area .......................................................................................... 10
4.
Nurse Station/Office Area.................................................................... 11
5.
Supply Area ......................................................................................... 11
6.
Isolation Areas ..................................................................................... 11
7.
Patient Areas ........................................................................................ 11
8.
Morgue ................................................................................................. 11
9.
Staff Sleeping Area .............................................................................. 11
10. Facility Layout Map………………………………………………….12
Recommended Staffing Ratios ................................................................... 13
ICS Diagram ............................................................................................... 14
Triage Screening ........................................................................................ 15
Medical Care Guidelines ............................................................................ 16
1.
Standards of Care ................................................................................. 16
2.
Infection Control .................................................................................. 16
3.
Oxygen Administration ........................................................................ 17
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May 21, 2009
4.
5.
6.
Tube Feedings ...................................................................................... 17
Fatality Management .......................................................................... 17
Management of Chronic Pre-existing Health Conditions .................... 18
Appendices
A.
B.
C.
D.
E.
F.
G.
H.
I.
Alternate Care Facility Cache Deployment……………………..………19
HIPAA During Emergencies ...................................................................... 23
1.
Treatment ............................................................................................. 23
2.
Notification .......................................................................................... 23
3.
Imminent Danger ................................................................................. 23
4.
Facility Directory ................................................................................. 23
5.
Public Health Exclusions ..................................................................... 23
Regulated Medical Waste Policy ............................................................... 25
1.
Purpose................................................................................................. 25
2.
Regulated Medical Waste .................................................................... 25
3.
Policy ................................................................................................... 25
4.
Procedures ............................................................................................ 25
FEMA Shelter Reimbursement Guidelines .............................................. 27
Level of Care Triage Matrix ...................................................................... 30
Medical Needs Shelter Job Action Sheets ................................................. 32
1.
Alternate Care Facility Unit Leader ..................................................... 33
2.
Medical Needs Shelter Medical Director ............................................. 34
3.
Administrative Assistant ...................................................................... 36
4.
Medical Needs Shelter Human Needs Manager .................................. 37
5.
Registration Assistant .......................................................................... 38
6.
Triage Unit Leader ............................................................................... 39
7.
Pharmacist ............................................................................................ 40
8.
Medical Needs Shelter Manager .......................................................... 42
9.
Nursing Staff ........................................................................................ 44
10. Caregiver…………………………………………………………….. 45
10. Emergency Medical Services ............................................................... 46
10. Mental Health Staff .............................................................................. 47
Forms………………………………………………………………………48
Common Definitions & Acronyms ............................................................ 49
References………………………………………………………………… 50
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May 21, 2009
Spokane Regional Health District
Medical Needs Shelter Plan
A. PURPOSE
The purpose of a Medical Needs Shelter (MNS) is to provide adequate, short term, supportive
medical care during a natural or technological disaster when the patient is displaced from their home
or specialized facility and cannot be accommodated at a general population shelter due to their
medical needs.
B. COMMON DEFINITIONS
Traditional dormitory shelters are temporary in nature and are designed for people displaced as a
result of emergency incidents or disasters. Traditional general population shelters can meet the needs
of individuals with minimal need for health checks (first aid level only), but they cannot meet the
needs of anyone requiring a consistent or above first aid level of care. Shelters will generally be run
by Faith Based agencies, non-profits (such as American Red Cross or Salvation Army) and/or local
municipalities with or without ARC assistance.
Medical Needs Shelters (MNS) are locations that will offer greater medical assistance than basic first
aid, but not to the level of an acute care facility or a hospital bed. Shelter residents may have
limitations in their personal care or self-protection abilities, mobility; vision, hearing, communication,
or health status. These limitations may be the result of physical, mental or sensory impairments; or
medical conditions. Some of these individuals may be reliant on specialized supports such as mobility
aides (wheelchairs, walkers, canes, crutches, etc.), communication systems (hearing aides, TTY’s,
etc.), medical devices (ventilators, dialysis, pumps, monitors, etc.), prescription medication, or
personal attendants. For some individuals, loss of these supports due to emergency related power and
communication outages, or transportations and supply disruptions, may be their primary or only risk
factor.
Hospitals, long-term care facilities and home health agencies are required to have plans in place to
shelter in place, evacuate patients in their care, transport them to safe and secure alternate facility and
support their medical needs. It should be noted that activation of a medical facility’s evacuation plan
and subsequent utilization of an alternate facility does not constitute a MNS. It will be assumed that
the staff of the long term care facility will accompany the patients and be the primary caregivers of
medical care to the residents. Supplies and equipment will also be the responsibility of the evacuated
facility. Due to the nature of this facility, limiting occupants to just those of the evacuated facility
should be given consideration.
C. LAWS, AUTHORITIES AND POLICIES
There are legal requirements set by federal, state and local legislative bodies that require local
jurisdictions to provide emergency management services to all individuals living and/or working
within their jurisdictional boundaries. In addition, those bodies have also set requirements that
address equal access to those services and defined what that looks like. Listed below are some of the
federal and state major citations that address these issues. Please note that this list is not exhaustive.
On the Federal level, the following apply:
1. Rehabilitation Act of 1973 § 104, 29 U.S.C. § 794 (2006) makes local governments responsible
for oversight of equal access by everyone to any program, service or activity that receives any
federal funding.
2. 42 U.S.C. §12132; 42 U.S.C. §12102(2)(B) & (C) says no one who is qualified may be excluded
because of a disability from any programs, services or activities provided by state and local
governments.
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3. 28 C.F.R. § 35.104 which defines disabilities and says individuals with disabilities may not be
excluded from public accommodations by commercial facilities.
4. Executive Order issued by President George W. Bush on July 22, 2004
5. Federal Civil Defense Act of 1950, as amended.
6. Public Law 93-288, "Disaster Relief Act of 1974" as amended by PL 100-707, "Robert T.
Stafford Disaster Relief and Emergency Assistance Act"
7. Public Law 96-342, "Improved Civil Defense".
8. Public Law 99-499, "Superfund Amendments and Reauthorization Act of 1986".
On the State level:
1. RCW 49 addresses the definition of Civil Liberties and Disabilities
2. RCW 70 Public Health & Safety
3. RCW 38.52 Emergency Management
4. RCW 51.12.035 Volunteers (refers to RCW 38.52 differentiating emergency workers and 41.24
RCW for firefighters)
5. WAC 118 Washington Military Department (Emergency Management)
D. PLANNING ASSUMPTIONS
1. Public education materials will be widely distributed to the public before a disaster strikes or
threatens and will emphasize the need for individual responsibility with regard to emergency
preparedness, including specific provisions for service animals and personal medical needs.
2. SRHD estimates that approximately 1% to 2% of any given population of shelterees will have
special medical needs. County departments of emergency management throughout Region 9 and
the Healthcare Coalition are strongly encouraged to develop a community registry of those
individuals. This information will help to identify the local populations that may require special
assistance in emergencies and will provide a starting point for resource allocation needs should
outside assistance be requested.
3. Hospitals, assisted living facilities, and nursing facilities are responsible for evacuation plans for
their facilities during emergency events and arranging for shelter needs for their clients/patients,
including reciprocal agreements with like facilities.
4. The American Red Cross does not provide medical care beyond basic first aid within its shelters.
5. An Emergency Declaration is made by the Governor or a Spokane County elected official
through the Spokane County Department of Emergency Management (DEM).
6. The general population and Medical Needs Shelters are the last available option for potential
shelter residents and will be utilized only when existing medical infrastructure is overwhelmed.
7. Medical Needs Shelters are not designed for pediatric patients or child with medical needs. All
children needing care will be sent to the nearest functioning hospital.
8. Medical needs shelterees may arrive with or without a personal assistant or caregiver.
9. Service animals will be co-located with their owners in the general population or Medical Needs
Shelters.
10. The Spokane Medical Needs Shelter Plan is compliant with applicable National Incident
Management System (NIMS), Incident Command System (ICS) and related asset typing
requirements.
11. Medical Need Shelters are expected to be operational for about 14 days.
E. DEFINING “SPECIAL NEEDS” POPULATIONS
A definition of a medical needs resident is an individual who meets the following criteria:
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1. Is unable to make sheltering arrangements on their own AND
2. Is not acutely ill AND
3. Has one or more medical and/or psychiatric conditions that require a level of medical care or
assistance that exceeds what a general shelter is able to provide.
It is anticipated that these shelters (both general population and Medical Needs) will be dynamic
environments and individuals may need to be reevaluated and reassigned from a Medical Needs
Shelter to a general shelter or vice-versa during their tenure.
The purpose of a Medical Needs Shelter (MNS) is to provide limited medical care that is necessary to
sustain life. The presence of any of the aforementioned conditions does not necessarily qualify a
person for admittance into the Medical Needs Shelter. Triage personnel will use a “problem-based”
approach considering the varying degrees of severity rather than a disease or condition-based
approach. Consideration will also include whether or not a caregiver/helper is present. Triage
personnel will assign potential shelterees to one of the following three shelter categories.
1. Traditional, Dormitory or Red Cross Shelter – Tier 1
a. Definition – Individuals who are independent prior to the disaster or emergency.
Some of these individuals may have pre-existing health problems that do not impede
activities of daily living and do not exceed the basic first aid capabilities of American
Red Cross (ARC) shelters.
b. Examples of pre-existing health conditions which can be accommodated within a
traditional shelter include:
 Epilepsy when controlled
 Diabetics who are stable
 Hemophilia
 Vision or hearing impairments
 Prosthesis
 Asthma if controlled
 Wheelchair bound person or other mobility related disabilities without other
medical needs and who is able to use shower or facilities with minimal
assistance
 Oxygen dependant with own supplies
 Conditions controlled by self-administered medications
 Persons requiring dialysis
c. Caveats:
 Persons who have more complex medical needs but who have a caretaker
who will stay in the shelter with them may be able to safely stay in a general
shelter and not require a higher level of care in a MNS.
2. Medical Needs Shelter - Tier 2
a. Definition – Patients who have no acute medical conditions but require some medical
surveillance and/or special assistance beyond what is available in a traditional
dormitory shelter.
b. Examples of health conditions which can be accommodated with a MNS include:
 Bedridden but stable and able to swallow
 Wheelchair bound with medical needs
 Person requiring assistance with tube feedings
 Various “ostomies” (i.e. colostomy or ileostomy)
 Draining wounds requiring frequent sterile dressing changes
 Persons with dementia who cannot be maintained in a traditional shelter
 Persons whose disability prevents them from sleeping in a cot
 Hospice patients
c. Caveats:
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 Individuals who were homebound with a caregiver should have their
caregiver stay in the shelter with them and bring any necessary medical
supplies.
 Persons suspected of having a communicable illness based on medical
history, symptoms (fever, rash, diarrhea or vomiting) or examination at
triage should be taken to a “non-urgent” care facility or nearby hospital for
evaluation and treatment.
3. Acute Care Facility –Tier 3 or Tier 4
a. Definition – Patients who need acute medical care such as individuals experiencing
trauma or injury.
b. Examples of health conditions which should be seen only in a hospital include:
 Patients who are ventilator dependent
 Pregnant women who are having contractions or are in labor
 Persons reporting chest pain any time in the last 24 hours or are experiencing
a heart attack
 Comatose individuals
 Uncontrollable or violent persons
 Contagious conditions that require special precautions
 Persons with infected wounds
 Others requiring the intensity of service only provided at a hospital
c. Caveats:
 Pediatric patients, even with uncomplicated medical conditions, should be
seen only in an acute care facility.
F. CONCEPT OF OPERATIONS
The MNS is designed to serve as a transitional area, with capability for a short term stay (up to 96
hours), with all patients then being returned to their homes or moved to other long-term care facilities.
The shelter staff will provide care under the written guidelines and with medical direction as set forth
here. When necessary medical care exceeds written protocols, shelter staff will consult with the MNS
Medical Director for specific guidance.
1. Operational Lead Agency & Management
The Disaster Medical Hospital Control (DMHC) will act as the Lead Agency for Medical Needs
Shelters in Region 9. As the Lead Agency, DMHC will activate of the MNS plan and coordinate
the opening and logistical support of MNS throughout Region 9. Other agencies and their roles
are described below:
 American Red Cross (ARC) will oversee the general population shelter and provide
logistical support for non-medical aspects of any MNS co-located with ARC general
shelters. In this setting, ARC will provide basic shelter services to all residents including
food and sanitation.
 Medical Reserve Corp (MRC) will provide staffing for the MNS. MRC can only operate
when assigned a mission number from Department of Emergency Management (DEM).
 Local Public Health will provide medical oversight for MRC when the MNS is operated
within its jurisdiction and when not activated by a hospital or other health care entity.
The Spokane Department of Emergency Operations, the Spokane Regional Health District, the
Disaster Medical Hospital Control, and the American Red Cross do not assume responsibility or
liability for shelter openings not authorized through the DMHC.
2. Pre-Activation Activities
In many instances of local emergencies and disasters, people with medical needs who need to be
sheltered number in the single digits or low double digits. Before activating the MNS plan at a
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general population shelter, a more ideal solution is to triage and place these patients in long term
care or acute care facilities that have empty beds available.
 ARC will work with the DMHC to identify available beds for those people who are in
general shelters who have complex medical needs that are not able to be accommodated
within the general needs shelter.
3. Preparation of Special Needs Populations for Evacuation
Individuals with special functional and medical needs should have certain information,
documentation and effects readily available in the event they must evacuate. For individuals in
group homes, resident/day care centers or other fixed facilities, evacuation kits should be
prepared for each person. An evacuation kit for individuals with functional needs should include:
 Vital records
 Disability-specific disaster preparedness inventory
 Medications, durable medical equipment and/or personal care supplies
 Plan for pet(s) or animal care
 Assistive technology supplies
 Any special dietary foods or supplements
An template of a personal medical information form can be found at:
http://emergency.cdc.gov/disasters/pdf/kiwy.pdf
4. Activation
Before the MNS plan can be activated a mission number needs to be assigned to the disaster,
exercise or event. The local Emergency Coordination Center (ECC) will consult with the DMHC,
ARC, SRHD and MRC to identify available facilities, prioritization of trailers and staffing.
Activation will result in visibility of the MNS in WATrac and RAMSES. Potential triggers for
activation of a MNS would include:
 An evacuation of the public has occurred or may occur, causing persons with medical
needs to seek shelter.
 Evacuation is expected to last more than eight (8) hours.
 Hospitals cannot accommodate surge of patients during an emergency.
 A large number of people with special medical needs have arrived at a general shelter and
ARC is unable to find placement for those individuals in long term care or acute care
facilities.
To request assets from the Region 9 Alternate Care Facility Cache, requesting entities should
follow the protocol outlined in Appendix A – Alternate Care Facility Cache Deployment.
5. Facilities
A MNS will be collocated with a general shelter but will be in a separate building/wing or in a
separate and distinct area of the general shelter. Common facilities for shelters would include:
schools, churches, or community buildings.
6. Patient Capacity
Each MNS is designed to accommodate up to 30 patients. Region 9 has two medical surge trailers
which can each support a 30 bed alternate care facility. Region 9 has a 40 bed E-Bed trailer that is
designed to support hospital based alternate care facilities.
Each MNS must report the number of residents daily. When a MNS reaches 80% capacity, every
attempt should be made to start rerouting traffic to other facilities. Agencies providing food and
other resources must be provided daily census updates as well.
7. Patient Records
A functional medical record must be established for every individual who is admitted to the
MNS. This record accompanies each patient throughout his/her stay and is available to the
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medical staff as needed for documenting any treatment provided and the patient’s response to
such. All records must be complete, legible, and thorough. Initially, each patient, if transferred
from a health care facility, will arrive at the MNS with some paper documentation. Upon arrival
to the MNS, additional components of the patient’s medical record will need to be added. A basic
admission package of paperwork should be minimally composed of a care plan with a history and
physical (H & P) Nursing documentation requirements should be scaled down as much as is
possible, and charting by exception is highly recommended. It is recommended that each MNS
adopt a standardized inpatient record system in the most simplified form possible, which will
facilitate the transfer and management of patient information.
8. Patient Tracking
Identification of the location and disposition of each shelter patient will be managed through the
following systems:
 Safe and Well Website – ARC supports a website where shelter residents may provide
information through a secure website to let friends and family members know that the
shelter resident is “safe and well”. For more information on this tool consult
www.safeandwell.org
 The MNS will provide a daily census of all patients to the DMHC.
9. Prescriptions
Residents for whom medications and supplies have been prescribed are encouraged to bring those
pharmaceuticals, supplies and devices necessary for health maintenance with them to the shelter.
These items will remain under the ownership and cognizance of the individual(s) to whom they
belong.
Relationships with local pharmacies and medical supply stores have been developed by ARC to
facilitate the procurement prescription medications.
 Sources of Prescription Services
o Local pharmacies may be used to support shelter pharmacy needs. Arrangements
should be made for placing orders from the shelter to local pharmacies, and for
direct delivery of orders from the pharmacies to the shelter.
o A MNS may also have relationships with host facilities such as local hospitals or
large clinics with in-house pharmacies such as Group Health or CHAS which
would facilitate prescription service.
 Shelter Prescription and Nonprescription Services
There is typically a wide variation of patient pharmacy needs scenarios at shelters:
o Patients with all required information for receiving their medications,
o Patients who do not have all the required information, but this information is
available through various services,
o Patients who do not have all the required prescription information and it is not
available through various services.
Addressing these scenarios in an efficient manner will need a triage officer in the shelter.
A pharmacist, pharmacy technician or nurse on site could serve as the triage officer. This
step will also require access to a computer with internet connectivity.
o If the triage officer determines that the patient has all their required information
or it can be accessed, the patient’s order can be sent to a local of host facility’s
pharmacy.
o If the triage officer determines that the patient has insufficient information
accessible to dispense their medications, the patient will be referred to the
prescriber at the shelter so that new prescriptions can be written.
o There may be an increased need for patient counseling. Patients may be using a
new pharmacy with a different inventory of generic drugs that will appear
different in appearance from the medications with which they are accustomed.
This needs to be explained to the patient at the time of dispensing so that
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

subsequent calls to the pharmacy can be avoided and allow for greater
medication adherence.
There are also two categories nonprescription items that may require special
consideration.
o Syringes and needles (for insulin, and other injectable medications)
o Exempt narcotics (cough syrups and antidiarrheals)
These items do not legally require prescriptions, but have legal restrictions associated
with their distribution. In both cases a, requestor is required to be 18 years of age or older
and have a valid photo ID. These items are also associated with a significant level of
abuse and misuse. It may be preferable to refer these needs to the triage officer for
evaluation. If it is determined that there is a valid need, a written prescription would
eliminate the legal restrictions associated with the nonprescription distribution. This
would also reduce the possibility of misuse or abuse during a period of confusion.
Receipt of Medications and Medical Supplies
There will need to be a designated area and shelter staff to receive deliveries. The staff
will then assume the responsibility of delivering the supplies to the correct patient.
Storage of Medications Requiring Refrigeration
There are various medications requiring refrigeration, ex gratis, insulin, certain
ophthalmics, topical preparations and injectable medications. A secured refrigerator with
access only by staff is needed. This would require staff to administer this.
10. Staffing
 Medical personal - SRHD has limited internal resources to operate or staff Medical Needs
Shelters. To address the staffing needs of the MNS, medical care will be provided by
Medical Reserve Corps volunteers.
 Volunteer Registration and Just-In-Time Training - Non-credentialed or spontaneous
volunteers will not be utilized in a Medical Needs Shelter. Volunteers must be credentialed
through ARC, MRC, SRHD or DEM. All volunteers and staff should sign in and sign out
every day. Volunteers should be assigned to an area of the MNS where they feel comfortable
and should receive Just-in-Time Training, as appropriate. All volunteers should be oriented
and supervised by the appropriate staff member. All volunteers should be issued and wear
MNS identification badges.
 Shift Changes - It is the responsibility of the MNS Manager to ensure that the staff is rotated
to prevent exhaustion. No staff member or volunteer should work more than a 12-hour shift.
Staggering shifts to overlap provides continuity. A buddy system should be developed to
ensure that staff members are monitored to prevent exhaustion. Staff members who refuse to
rest or take a break should be identified, and the MNS Manager should be notified.
11. Security
Security is needed to maintain the safety of the staff and residents and family members arriving at
the MNS. Assigned security officers/law enforcement for the Medical Needs Shelter component
should be provided through a request made through the Department of Emergency Management
(DEM). The primary role of the facility security officer (FSO) is to assure the safety of the
residents. Local 911 should always be contacted first in the event of any serious reportable
security or criminal threat. Duties include, but are not limited to:
 Check in with the Medical Needs Shelter Director;
 Establish one main entrance for the flow of residents into the SNS;
 Advise Medical Needs Shelter Director on security coverage and schedules;
 Ensure that the entranceway to MNS remains clear and accessible;
 Direct emergency and supply vehicles to appropriate locations;
 Maintain law and order, by trying to resolve problems that may arise among residents;
 Monitor exits and restricted areas;
 Ensure that the area remains secure;
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
Ensure areas that are not to be used during the SNS operation are secured and identified
as off limits (interior spaces of the building that are not to be utilized should be identified
with a “Do Not Enter” sign);
 Inform Medical Needs Shelter Director of any concerns or problems;
 Protect the safety of all persons; and
 Respond to emergencies at the MNS as needed.
Medical Needs Shelter staff members are to wear identification badges at all times displaying
name, role, and agency.
12. Transportation
Shelterees, caregivers, providers and agencies should exhaust all available transportation
resources to include family, friends, or neighbors before requesting public assistance for
transportation to routine medical appointments
 Non-emergency transportation will be arranged through the Spokane Department of
Emergency Management with local transportation providers if unavailable through
family and/or friends.
 Emergency Medical Services (EMS) for state shelters will be provided through normal
9ll channels for the jurisdiction where each shelter is located.
13. Communications
 Local municipalities should be prepared to provide back-up communication to MNS located
within their jurisdiction.
 In addition to telephones (landline and cell), each shelter should consider having an 800 MHz
radio with an operator available in case of traditional communications failure.
 The MNS should have internet access via wireless internet via internet cards for laptops or
access to login and password information for local building wireless networks.
14. Set-up
The staff should begin setting up to receive residents and supplies as soon as the facility
representatives have opened the facility and the shelter areas have been secured. Shelter
Managers and the MNS Manager should perform a final walk through to evaluate the overall
functionality, its operational ability, and accessibility for medical needs shelterees. Significant
issues must be documented and reported immediately to SRHD for recommendations on how to
address the deficiencies.
15. Signage
Shelter signage will be found in the ACF trailers. For additional signage or current digital files
and/or artwork use the following websites:
 WA Department of Health - http://www.doh.wa.gov/phepr/signs/
G. FACILITY LAYOUT
1. Arrival and Entrance Area
Posted signs should direct traffic to the entrance of the facility. It should be noted that some
incoming residents may, because of their condition, have to be assisted into the facility (via
wheelchair or gurney).
2. Patient Registration/Information Area
Shelter Managers initiate the set up of the Registration area, which will be located near the main
entryway of each facility. If this is a dual shelter then paperwork will be given here to assess
whether the patient will reside in the general shelter or the Medical Needs Shelter.
3. Triage Area
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Before residents are admitted to the Medical Needs Shelter their level of care needs will be
assessed by a triage nurse or a member of the triage team. The triage area should be located
adjacent to the registration area and must be screened to provide for some level of privacy. The
purpose of Triage is to assign shelterees to the ARC general shelter, to the MNS, or to transport to
an acute care facility.
4. Nurses Station/Office Area
The nurses’ station/office area should include a first aid station and a medical supply area. A
nurse should staff the first aid station and the MNS Manager should oversee the operation. The
medical supply area should be secured and monitored by the MNS Manager. All pre-identified
medical supplies should be delivered to the MNS Manager and should be logged in when
received. The general supplies for the MNS should be stored in an area away from public areas.
An Inventory Control Sheet should be maintained for recording any supplies used.
5. Supply Area
Supplies for the Medical Needs Shelters should be stored in a lockable/secure room with limited
access. With the exception of refrigerated medicines, any pharmaceuticals on hand must be kept
in a double locked cabinet. Refrigerated medicines must be stored in a lockable refrigerator that
is used only for that purpose.
An inventory control sheet must be maintained for recording the status of supplies. The
supervising nurse or designee will verify items and quantities as they arrive into the shelter.
Discrepancies must be noted on the inventory sheets. When the MNS is closed, the MNS
Manager or designee, should complete a final inventory of the remaining emergency management
agency supplies and calculate the total quantity used. The inventory sheets are to be returned to
the SRHD.
6. Isolation Areas
Three categories of persons should be assigned to isolation in separate rooms away from the
Medical Needs Shelter and general shelter:
 Persons with communicable illnesses
 Persons with significantly compromised immune systems
 Persons that are deceased
7. Patient Areas
SRHD will use the standard of 60 square feet per Medical Needs patient in estimating the
shelters’ capacity. This provides ample room for the patient as well as the caretaker or
companion animal.
8. Morgue Area
A temporary morgue needs to be established in case of a death in the MNS. The morgue area
should be an isolated room that is away from the general congregation areas. A sign should be
posted to designate the temporary morgue area, if and when it is needed. The deceased person
should be shrouded with a sheet or blanket. The MNS Manager should notify the Disaster
Medical Hospital Control and/or the appropriate authorities of any deaths that occur.
9. Staff Sleeping Area
A staff sleeping area should be located in a quiet area of the MNS, preferably away from the main
traffic. The ideal area is one where there is limited or no natural light to allow people to sleep
during the day.
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MEDICAL NEEDS SHELTER LAYOUT
ENTRANCE
Restrooms
Security
Initial Triage
Station
Shelterees Arrive
Security
Registration &
Information
Station
Kitchen
and
eating
area
Area for
residents to fill
out forms
(chairs)
Nurse
Manager’s
Office
Nursing
Station
MNS
Residents
General
Storage
Triage Area to assess need level
Medical
Supplies &
Equipment
MNS Residents
Sleeping areas
Health/Medical
Staff Volunteers
Limited Access
Entrance
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H. RECOMMENDED STAFFING RATIOS
The following staffing ratios are estimated for about 30 shelterees, with flexibility allowed based on
acuity of care needed by residents. Each shelter has the autonomy to adjust staffing levels and
patterns as needed to ensure adequate medical care and oversight can be administered.
STAFF
ACF Unit Leader
Medical Needs Shelter Director
Administrative Assistant
MNS Human Needs Manager
MNS Registration Assistant
Triage Unit Leader
Pharmacist
MNS Manager (RN, ARNP, PA)
Nursing Staff (RN/LPN)
Caregivers
Paramedics/EMTs
Mental Health Staff
Security Staff
SHIFT
Days
Nights
Days
Nights
Days
Nights
Days
Nights
Days
Nights
Days
Nights
Days
Nights
Days
Nights
Days
Nights
Days
Nights
Days
Nights
Days
Nights
Days
Nights
RATIO
1/shift
On Call
1/shift
On Call
1/shift
1/shift
1/shift
On Call
2/shift
1/shift
1/shift
1/shift
1/shift
On Call
1/shift
1/shift
4/shift
2/shift
6/shift
6/shift
2/shift
On Call
1/shift
On Call
1/shift
1/shift
COMMENTS
SRHD/DMHC
MRC/SRHD
MRC/SRHD/DEM
ARC
MRC/SRHD/DEM
MRC
MRC
MRC/SRHD
MRC/SRHD
Shelteree
DEM/Student EMTs
MRC/DEM
DEM
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I. ICS DIAGRAM
Emergency Coordination Center
Operations Section Chief
ACF Unit Leader
Medical Needs Shelter A
MNS Director
MNS Medical Manager
Admin Assistant
Facility Manager
Security
Registration Assistant
Triage Unit Leader
Nursing Staff
Caregivers
Pharmacist
Mental Health Staff
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J. TRIAGE SCREENING
Initial questions will be asked of shelter individuals as they enter into the facility to determine whether
they may have a medical emergency or are presenting significant emerging symptoms. The shelter will
use the most current ARC Shelter Intake and Assessment Tool for initial triage.
The following establishes reasonable triage criteria a qualified medical professional might employ during
a public health event resulting in a large scale displacement of citizens from their normal place of
residence. These criteria should be considered in determining whether an individual with special medical
needs should be taken to a hospital for emergency care and admission screening or whether that
individual can be accommodated at the medical needs shelter. Those exhibiting critical and/or emergency
health indicators should receive immediate emergency care by EMS or qualified staff onsite, until
transport can be achieved. Those answering “Yes” on the shelter Initial Intake and Assessment Tool
question “Do you have medical or health concern or need right now” should receive immediate attention.
Examples:
 The person has suffered injuries or wounds that affect one or more body systems by blunt,
penetrating or burn injury and may be life altering or life threatening conditions.
 The person is experiencing respiratory distress.
 There is partial or complete airway obstruction and the person is unable to establish or maintain
airway.
 There is a change in consciousness; the person does not follow commands or is unable to move
extremities.
 Signs & symptoms of shock (e.g., systolic blood pressure <90, heart rate >120).
 Uncontrolled bleeding.
 Extremities with uncontrolled bleeding, loss of pulse.
 There is any penetrating injury.
 Evidence of heart attack or stroke, or CPR initiated.
The consensus criteria for those individuals who do not require immediate care in an acute care facility,
but have medical needs to the degree that their health and well-being may be in jeopardy (especially
under the extraordinary conditions that may prevail in the circumstances surrounding mass displacement
of residents):
 Those individuals who depend on a caregiver to assist with the accomplishment of activities of
daily living (ADLs) and for whom a care-giver and a safe environment are not available.
 Those individuals who are technologically dependent; i.e., require oxygen and/or some type of
mechanical device to sustain normal function and enable ADLs, e.g., oxygen concentrators or
portable O2 units, respirators, access to periodic dialysis treatment, etc.
 Those individuals who are dependent on specialized medications in order to maintain their health
status and for whom those medications are unavailable due to the circumstances. This may
include those who have been on home IV therapy.
 Additionally, some individuals may be at high risk during a "population displacement" event who
would not otherwise be at risk. Examples include pregnant and the newborn or post-surgical
patients recently released from a hospital.
Federal law under the EMTALA rules prohibits hospitals from "dumping" patients and hospitals are
reluctant to turn anyone away once they have been presented or present themselves to the ER. This is
why appropriate medical needs screening is so important to maintaining our hospital capability of
providing care to those in need of acute care services.
People whose needs exceed the level of care that can be provided at an MNS should be referred to a
skilled nursing facility or hospital. The Nurse Manager should contact the Disaster Medical Hospital
Control to coordinate referrals, transportation services, etc. If the person or caregiver is able to provide
transportation then clear, concise directions should be given to the closest appropriate facility. Whenever
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possible, a map and written address should be provided. For other residents, transportation should be
arranged to the closest appropriate skilled nursing facility or hospital. If an ambulance transport is
necessary, it should be arranged through Emergency Medical Services.
K. MEDICAL CARE GUIDELINES
All shelterees requiring any form of medical treatment or prescription, over the counter medicines,
supplies, or equipment must be evaluated by the Triage Staff at check in. The shelteree’s medical history
will be taken and a clinical assessment will be made at that time. The history and clinical assessment will
determine how to classify and manage the symptoms and conditions.
Shelteree history may be obtained from the patient, family, caregiver or an observer. Required
information for those needing medical treatment includes the following:
 Time of the incident or onset of symptoms
 Subjective symptoms, such as location and description of pain or discomfort
 How the injury occurred
 Self-treatment given and the results
 Relevant medical history such as:
o General state of health
o Previous health problems and conditions
o Prescription and over-the-counter medications
o Special medical supplies/equipment
o Allergies
o Name and telephone number of personal physician
o Date and reason for last hospitalization
The clinical assessment includes the following:
 General appearance, age, sex, and weight
 Vital signs as appropriate, such as pulse, respiration, temperature, blood pressure, and P02
 Objective signs, such as level of consciousness, skin temperature and color, and pupil status
1. Standards of Care
During medical surge emergencies, there may be shortages of healthcare resources that will
necessitate modified standards of care. The goal of an organized and coordinated response to a
mass care event is to maximize the number of lives saved. Changes in the usual standards of
health and medical care for those affected will likely be required to achieve the goal of saving the
most lives in a mass casualty/mass care event. Rather than doing everything possible to save
every life, it will be necessary to allocate scarce resources in a different manner to save as many
lives as possible. Protocols for triage need to be flexible enough to scale to the size of such an
event and will depend on both the nature of the situation and the speed with which it occurs.
2. Infection Control Guidelines
For specific infection control recommendations please consult:
 APIC “Infection Prevention and Control for Shelters During Disasters.”
http://www.apic.org/Content/NavigationMenu/EmergencyPreparedness/SurgeCapacity/S
helters_Disasters.pdf
 Infection Control Recommendations for Prevention of Transmission of

Respiratory Illnesses in Disaster Evacuation Centers
http://emergency.cdc.gov/disasters/disease/respiratoryic.asp
Infection Control Guidance for Community Evacuation Centers Following
Disasters http://emergency.cdc.gov/disasters/commshelters.asp
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
Infection Control Recommendations for Prevention of Transmission of Diarrheal
Diseases in Evacuation Centers
http://emergency.cdc.gov/disasters/disease/diarrhea-evac.asp
3. Oxygen Administration
Residents may be permitted to follow their physician’s instructions about the intermittent use of
oxygen to relieve the symptoms of chronic obstructive lung disease or some related condition.
Persons requiring 24-hour oxygen and/or who are electric dependent, should be evaluated for
transfer to a skilled health care facility. Use of the resident’s own portable oxygen tanks is
encouraged. Residents utilizing oxygen concentrators are encouraged to bring their equipment
with them for use while electrical power is available. Whenever possible, residents should have
battery backup and provide a small tank in case of power failure or switch to portable oxygen
tanks for the duration of the shelter period.
The MNS Manager should request oxygen delivery after the resident has been triaged or the need
for oxygen has been determined. Instructions for the use of portable oxygen provided by the
shelteree’s own physician would be followed to the maximum extent possible.
One compressed oxygen tank (E-cylinder) is able to support only one patient on low-flow oxygen
(2 liters/minute) for 4 to 8 hours. As a result, the preferable method of administering oxygen in a
shelter environment is through the use of liquid oxygen, particularly those residents who are
receiving oxygen 24-hours per day or are being administered a high volume of oxygen.
4. Tube Feedings
Gravity or bolus tube feedings should be administered by the nursing staff as per the orders of the
shelteree’s personal physician. In general, the instructions of the shelteree’s own physician should
be followed to the maximum extent possible. Similarly, efforts should be made to provide the
shelteree with a tube feeding product (baby formula) which meets the basic requirements as
prescribed by the shelteree’s physician, should the shelteree’s own supply be fully utilized.
5. Fatality Management Procedures
In the event that a shelteree expires in the shelter during the emergency, these procedures are to
be followed:
 Notify onsite Security of the death.
 Quietly relocate the expired resident to a holding area away from the general area.
 Cover the body with a sheet or enclose in a body bag, if available.
 Notify the MNS Manager.
 If a caregiver or next of kin is available in the shelter, their wishes should be expressed to the
MNS Manager.
 The body should not be removed until released by law enforcement.
 The resident’s chart should be annotated with all information concerning the event and the
directions received from the MNS Manager.
Fatalities fall into two main categories: (1) unnatural causes, such as catastrophic events of nature
(hurricane, flood, earthquake, tsunami), bioterrorism (use of agents such as anthrax, smallpox,
Ebola) and terrorist attacks (World Trade Center, arson-related forest fires), and (2) natural
causes such as natural disease processes (pandemic influenza or Severe Acute Respiratory
Syndrome (SARS), heart attacks, COPD, etc.
The management and disposition of all unnatural deaths come under the primary jurisdiction of
the Spokane County Chief Medical Examiner. The management of natural deaths resulting from
natural disease processes is the primary responsibility of the locality in which they occur.
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6. Management of Chronic Pre-existing Health Conditions
The physical and psychological stress of a disaster may aggravate a patient's chronic condition.
Therefore, Medical Needs Shelters providers should identify persons with chronic illnesses who
are affected by a disaster and be on the alert for exacerbation of their symptoms.
For residents with chronic health conditions, Medical Needs Shelters providers may:
1. Assist in maintaining their current health regimen by:
 Replacing or providing needed medications or supplies
 Arranging for special diets (diabetic, low sodium, etc.) with and providing assistance
with feeding, such as providing straws, cutting up meats
 Providing a private area for individuals needing assistance with their bathing and dressing
 Arranging for a barrier-free environment
 Referring to personal or other physician as needed
2. Plan to relocate certain persons from the shelter to alternative housing as necessary.
Relocation may be recommended for a person who:
 Has severe asthma (to prevent exacerbation of illness)
 Has a compromised immune system due to disease or medication. This includes any
serious chronic or terminal illness that would put the patient at risk if exposed to other
shelter residents who have colds or other illnesses
 Has a communicable disease and requires isolation
 Is severely disabled, and the facility cannot be made a barrier-free environment.
 Is mentally or physically unable to function in a shelter environment; may need to consult
with American Red Cross or the Disaster Medical Hospital Control regarding appropriate
placement
 Is an active substance abuser. Medical Needs Shelters providers may need to consult with
the Disaster Medical Hospital Control.
3. All other necessary procedures that require a physician’s order should be referred to the
Nurse Manager. The Nurse Manager should contact the Incident Commander or the Medical
Director for consultation and/or specific orders.
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APPENDIX A
ALTERNATE CARE FACILITY CACHE DEPLOYMENT
Purpose
The Region 9 Alternate Care Facility (ACF) Cache consists of supplies and equipment used to
establish alternate care facilities in Region 9. Two 18 foot cargo trailers contain basic equipment
(cots, linens, gowns, gloves, lights, etc.) to establish two 30 bed alternate care facilities. A third
trailer contains 40 E-Bed medical treatment beds to support hospital-based alternate care facilities.
This policy guides mobilization of components of the Region 9 ACF Cache.
About the Cache
The ACF Cache(s), a Region 9 Healthcare Coalition asset, is stored at:
Spokane County Fire District 4, Station 44
3219 E. Chattaroy Rd, Chattaroy, WA 99003
509-467-4500
The cache is intended to bolster hospital surge capacity during a local/regional disaster or a preplanned event. The cache is not a self-contained hospital unit; it does not include shelter. It is set up
as a shipping package that can arrive at a hospital or non-hospital facility and supply that facility
with the hospital disposables and basic equipment required for startup.
Each 30 Bed Cache is loaded in an 18’ cargo trailer with the Region 9 Health Care Coalition Logo
on each side for identification. The trailers utilize a 2 5/16 inch standard trailer ball and a standard 6
pt round trailer light plug configuration.
The 40 E-Bed Cache is loaded in a trailer stored at SRHD.
A current inventory list of the trailer contents can be found in each trailer. The ACF cache inventory
can be obtained from the Health Care Coalition Executive Council as well as the DHMC.
Requesting the Cache
The following conditions set the stage for deployment of the ACF cache to a locale in Region 9
during a medical disaster:
1. Local surge capacity is exceeded or anticipated to be exceeded:
a. Each hospital in Region 9 has some ability to increase its capacity in the event of a
disaster producing a surge of in-patients.
b. When surge capacity is exceeded and it is not possible to divert patients to another
hospital facility then opening a local ACF is the next course of action.
c. The hospital administrator or their designee determines if surge capacity is exceeded.
d. Information on the ability to divert patients to other institutions is provided through
web-based bed tracking programs such as RAMSES or WATrac as well as direct
communication from the Disaster Medical Hospital Control (DHMC).
e. Geographic isolation and patient transport capabilities are taken into consideration.
2. There is a local plan in place for an Alternate Care Facility that would appropriately utilize
the materials in the Region 9 ACF cache.
a. This may be a pre-event plan designed by the hospital
b. This may be a pre-event plan developed by the local public health jurisdiction.
c. This may be a pre-event plan developed by local emergency management
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d. This may be an action plan developed under Incident Command during an
emergency.
e. Or it may be any combination of a-d
f. At minimum the plan must:
i. Designate an appropriate facility.
ii. Meet staffing needs.
iii. Provide a means of transportation of cache materials
iv. Plan for cleaning and returning reusable materials
v. Understanding that disposable or damaged items need to be replaced by the
requesting organization.
3. The request for the cache may be made by any of the following entities with Region 9:
a. The Hospital Administrator or designee
b. The County Health Officer or designee
c. The County Department of Emergency Management Director or designee
4. Requests for an ACF cache from outside of Region 9 will be made to emergency
management who will contact the Disaster Medical Hospital Control (DMHC) to identify if
assets are available for deployment in other WA Regions or in other states.
Request for ACF cache will be made by contacting the duty officer at the DMHC by:
1. Phone: (509) 473-7100
2. Pager: (XXX) XXX-XXXX
3. Fax:
(509) 473-7508
4. Email:
TBD
Approving Cache Deployment
1. The request for the cache will be directed to the DMHC.
2. If there are no eminently competing or potentially competing requests for cache deployment,
then the request will be administratively approved by the DMHC.
3. If there is a competing or potentially competing request(s) for cache deployment then the
intent of the Region 9 Healthcare Coalition is that the cache be sent where it will do the most
public good.
a. It is the responsibility of requesters to make their case by providing complete and
reliable information to the DMHC.
i. Patient count and condition of patients that will need ACF beds
ii. Existing acute care bed capacity
iii. Ability to divert patients
iv. Ability to care for ACF patients
v. Transportation issues to and from the requesting facility
b. It is the responsibility of the DMHC to receive, gather, and collate supporting
information.
c. Arbitration of competing requests will made by the DMHC.
Procedures:
Deployment Procedures
Upon approval of deployment, the DMHC will set the deployment in motion.
1. DMHC will communicate with the Spokane Combined Communication Center (509-5328900) who in turn has dispatch information for the Fire District 4 Duty Officer, where the
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2.
3.
4.
5.
6.
7.
ACF trailers are stored. If District 4 has personnel and equipment available for transport of
the ACF trailers, they will coordinate transport with the requesting facility. If District 4
resources are not available, alternate contacts for transportation of the trailers are:
a. Transportation Alternate #1 Department of Emergency Management Duty Officer
i. Pager: (509) 477-4209, enter 0822
ii. Fax: (509) 477-5759
b. Transportation Alternate #2
i. Phone: (XXX) XXX-XXXX
ii. Pager: (XXX) XXX-XXXX
iii. Fax:
(XXX) XXX-XXXX
iv. Email:
TBD
The cache will be transported directly to the designated ACF host entity.
The trailers utilize a 2 5/16 inch standard trailer ball and a standard 6 pt round trailer light
plug configuration.
With deployment of an ACF cache the DMHC will assign a deployment team to assist the
receiving entity in:
a. Set-up of the cache supplies to include beds, supplies, oxygen, and communication
equipment.
b. Assist with set-up of processes regarding communication with the control hospital
regarding logistical needs and patient tracking.
c. Assist with utilization of community partners for logistics or staffing support.
Unloading is the responsibility of the receiving entity.
Cache to be setup and used per the local ACF plans with the assistance of the deployment team.
The requesting agency is responsible for keeping track of disposable or damaged items used
during the deployment. An inventory list for tracking supplies will be given to the requesting
agency.
With Demobilization
1. The requesting entity is responsible for standard cleaning of all reusable items.
2. The requesting entity and/or emergency management is responsible for transporting the cleaned
reusable equipment and unused disposable supplies back to the Region 9 Storage Facility within
30 days after the emergency ends.
3. The Disaster Medical Hospital Control will inventory the cache with a representative from the
receiving agency.
Replenishing the Cache
1. Re-supply will be based on the availability of funding. The requesting entity shall utilize any
available resources to replenish the items used or damaged during the event. Region 9 will work
cooperatively, utilizing available funding and grant opportunities to replenish used supplies to
prepare the ACF cache for redeployment.
2. The requesting entity shall make any recommendations based on actual use for additional
supplies and equipment necessary for utilization of the ACF cache.
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Storing the Cache
1. Region 9 Healthcare Coalition personnel will inspect the ACF cache materials annually and will
provide a written report as to the condition of the cache including information on storage damage,
outdates, inventory discrepancies and so on.
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APPENDIX B
HIPPA DURING EMERGENCIES
During an emergency, providers and health plans covered by the HIPAA Privacy Rule can share
patient information in the following ways:
1. TREATMENT
Health care providers can share patient information, as follows, to provide treatment.

Sharing information with other providers (including hospitals and clinics)

Referring patients for treatment (including linking patients with available providers in areas
where the patients have relocated), and coordinating patient care with others (such as
emergency relief workers or others that can help in finding patients appropriate health
services). Providers can also share patient information to the extent necessary to seek
payment for these health care services.
2. NOTIFICATION
Health care providers can share patient information as necessary to identify, locate, and notify
family members, guardians, or anyone else responsible for the individual's care, or the
individual's location, general condition, or death. The health care provider should get verbal
permission from individuals, when possible; but if the individual is incapacitated or not available,
providers may share information for these purposes if, in their professional judgment, doing so is
in the patient's best interest. Thus, when necessary, the hospital may notify the police, the press,
or the public at large to the extent necessary to help locate, identify, or otherwise notify family
members and others as to the location and general condition of their loved ones.
In addition, when a health care provider is sharing information with disaster relief organizations
that, like the American Red Cross, are authorized by law or by their charters to assist in disaster
relief efforts, it is unnecessary to obtain a patient's permission to share the information if doing so
would interfere with the organization's ability to respond to the emergency.
3. IMMINENT DANGER
Providers can share patient information with anyone as necessary to prevent or lessen a serious
and imminent threat to the health and safety of a person or the public -- consistent with applicable
law and the provider's standards of ethical conduct.
4. FACILITY DIRECTORY
Health care facilities maintaining a directory of patients can tell people who call or ask about
individuals whether the individual is at the facility, their location in the facility, and general
condition.
The HIPAA Privacy Rule does not apply to disclosures if they are made by entities not covered
by the Privacy Rule. For instance, the HIPAA Privacy Rule does not restrict the American Red
Cross from sharing patient information.
Source: United States Department of Health and Human Services
http://www.hhs.gov/ocr/hipaa/emergencyPPR.html
5. PUBLIC HEALTH EXCLUSIONS
HIPAA does not prohibit disclosure for public health purposes.
The HIPAA is intended to protect the public from unauthorized access to, use of, and disclosure
of individually identifiable health information. It places responsibility on health care providers to
avoid using or disclosing protected health information (PHI) unless authorized by the person to
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whom it pertains, or unless the disclosure or use is required or permitted by regulation or law.
Specifically excluded from the requirement for individual authorization are disclosures for public
health activities. This means that sharing PHI for public health purposes is permitted as long as
the agency to which the information is provided is legally authorized to collect and receive the
information.
This specific exclusion was allowed because public health authorities have a legitimate need for
PHI to ensure public health and safety, and because public health agencies have a track record of
protecting the confidentiality of PHI. The HIPAA privacy rule attempts to strike a balance
between individual privacy rights and the need for public protection.
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APPENDIX C
REGULATED MEDICAL WASTE POLICY
1. PURPOSE
To protect shelter staff, clients and visitors from exposure to potentially disease-causing waste
materials, and to ensure compliance with all local, state and federal regulations.
2. REGULATED MEDICAL WASTE (RMW):
Any waste materials that are capable of producing a disease by an organism likely to be
pathogenic to healthy humans, such as the following:
 Discarded cultures and stocks of microorganisms, specimens, vaccines and associated items
containing organisms likely to be pathogenic to healthy humans.
 Human blood and certain body fluids as defined by OSHA.
 Items saturated or caked with human blood or body fluids that would release blood/body fluid
in a liquid or semi liquid state if compressed or would flake if handled.
 Human tissue or anatomical wastes.
 Sharps (needles, syringes with attached needles, and scalpel blades: Needles, syringes with
attached needles, scalpels, scissors lancets, guide wires and glass pasture pipettes, etc.).
 Animal carcasses, body parts, bedding and related wastes when intentionally infected with
organisms likely to be pathogenic to healthy humans.
 Any residue that results from the clean up of a spill of infectious waste.
 Any waste contaminated by or mixed with infectious waste.
3. POLICY
Regulated medical waste must be properly segregated and disposed of in accordance with this
policy. Any waste that meets the above definition must be considered RMW. The disposal of
RMW is both highly regulated and very costly. Facility staff must use the utmost care to
segregate all waste materials properly. No Radioactive or Hazardous Waste shall be placed within
the RMW stream. Also, no normal unregulated trash or recyclable materials shall be put into
RMW containers.
4. PROCEDURES





RMW containers must be provided and placed by a Shelter Public Health representative (i.e.,
a Public Health Nurse, Environmental Health Services or other designated representative), a
specially assigned staff member through the Shelter ICS organization, or a services vendor
contracted for the collection and disposal of RMW under the direction of the above Shelter
representative.
The SRHD maintains a supply of portable RMW containers and should be contacted to
arrange for delivery, installation, collection and disposal.
All used sharps must be disposed of in a puncture resistant sharps disposal container. Full
sharps disposal containers are then placed in a Regulated Medical Waste Container for final
disposal. Non-sharp RMW other than animal carcasses must be placed in a Regulated
Medical Waste Container lined with red bio-hazard bags.
Once a container is full, the top must be taped closed and properly labeled with the Facility
name, date and a contact number.
RMW containers must be removed and managed by a Shelter Public Health representative
(i.e., a Public Health Nurse, Environmental Health Services or other designated
representative), a specially assigned staff member through the Shelter ICS organization, or by
a specially assigned staff member, or a services vendor contracted for the collection and
disposal of RMW.
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APPENDIX D
FEMA SHELTER REIMBURSEMENT GUIDELINES
Background: When a major disaster, such as a hurricane, threatens the population, certain
medically dependent individuals may need to be evacuated from the affected area to Medical
Needs Shelters where professional care can continue to be provided. Typically, local or State
government officials will order the evacuation of Special Needs (SN) people in advance of
calling for mandatory evacuation of the general population. Each locality has designated SN
shelters and the State has designated regional SN shelters. Special Needs (SN) people are
medically dependent individuals who have physical or mental conditions that limit their ability to
function on their own and who cannot provide for or arrange their own transportation or
sheltering outside a risk area.
Guidance:
1. Medical Treatment. Medical treatment costs are not eligible for reimbursement under the
FEMA Public Assistance Program. For the purposes of this guidance, “medical treatment” is
treatment administered by licensed physicians and nurses, and is recoverable, directly or
indirectly, from private insurance plans, public insurance plans such as Medicare and Medicaid,
from other forms of Federal, State or local funding, or from sources such as donations, fundraising, and the like.
Costs eligible for FEMA reimbursement are only those costs that result from the evacuation,
transportation, and housing of SN people and required staff at the shelter location, and the
return/reentry of SN evacuees and staff, as further described in this guidance document.
2. Eligible Applicants.
(a) Only State and local governments, private nonprofit organizations, and Indian tribes or
authorized tribal organizations that own or operate qualifying medical facilities under 44
CFR 206.221(a)(5) are eligible applicants.
(b) Sheltering-related housing costs incurred by the sheltering facility should be claimed
through the applicant who evacuated its facility or who sponsored the evacuation of SN
people.
3. Eligible Facilities. Only facilities designated or approved by the State or local government as
eligible SN evacuation facilities and that are located in the disaster area are eligible for FEMA
reimbursement of SN sheltering costs.
4. Eligibility of Straight-Time, Overtime and “Emergency Pay.”
(a) Straight Time Wages. 44 CFR 206.228(a)(4) makes the straight or regular time wages,
salaries and benefits of an applicant’s permanently employed personnel performing
emergency work not eligible for FEMA reimbursement.
(b) Overtime Wages of permanently employed personnel performing emergency work are
eligible for FEMA reimbursement. For the purposes of determining the circumstances under
which employees are eligible for overtime pay, FEMA may rely on an applicant’s written
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policies and union contracts as they apply to normal, non-disaster circumstances. In no
event, however, will FEMA reimburse employee compensation paid for the first forty (40)
hours of emergency work during a consecutive seven (7) pay period or for the first eight (8)
hours worked on any single day that would normally be paid at the straight time rate. In
addition, overtime wages are only eligible for reimbursement for employees actually engaged
in performing work eligible under FEMA’s regulations and policies.
(i) FEMA will not reimburse overtime pay for exempt employees unless such
employees are paid overtime pay during normal, non-disaster circumstances.
(c) Emergency Pay.
(i) When an applicant closes its facilities following a declaration of an emergency by
the State or the local government but requires that essential personnel report to work and
perform eligible emergency work during the facility closure pursuant to an existing written
policy or union contract, FEMA will reimburse the Emergency Pay of non-exempt essential
personnel to a limit of one and one-half (1½) times an employee’s regular hourly base pay
for hours worked during the facility closure.
(ii) FEMA will reimburse Emergency Pay for exempt employees required to work
during the facility closure at an hourly rate not in excess of one-times an exempt employee’s
regular base salary calculated on an hourly basis, but only for exempt employees whose
duties are not executive or professional in nature.
(iii) Pay that compensates personnel for time not actually worked, such as standby, oncall, or rest period pay, is not eligible for reimbursement. Pay in addition to normal hourly
pay that compensates an employee for actual eligible work performed, such a shift
differential pay, is eligible for reimbursement.
5. Eligible Costs/Eligible Work
Only costs directly related to SN evacuations and sheltering are eligible for reimbursement.
FEMA’s regulations require that it reimburse only costs that it deems reasonable.
(a) Records Requirements.
(i) An applicant’s reimbursement request must account for costs incurred in preparing,
evacuating, and returning SN people and staff separately from costs incurred to house SN
people and staff at the sheltering facility.
(ii) An applicant’s reimbursement request must include the number of SN people
evacuated and housed at the sheltering facility, the name and location of the sheltering
facility, and the beginning and ending dates of the evacuation.
(iii) An applicant’s reimbursement request for staff compensation must describe the
duties performed by each staff member or by type of staff (custodial, security, etc.) being
claimed. Claims for staff housing costs must be accompanied by third party invoices.
(b) Staff Compensation.
6/17/2017
FEMA will only reimburse the overtime or Emergency Pay – but not both - of staff
performing non-medical services and who are reasonably required for the following types of
work (i)
Preparing to evacuate and assisting in the evacuation of SN people;
(ii)
Providing non-medical direct assistance to SN people, including “Adult Daily
Living” assistance, in preparation, evacuation, and sheltering of SN evacuees;
(iii)
Preparing for and returning SN people to their evacuated location.
(c) Equipment and Supplies. Consumable and non-consumable supplies are eligible for
FEMA reimbursement only to the extent they exceed normal day-to-day usage in non-disaster
situations.
(d) Transportation Costs. Eligible costs include the costs of transporting SN people to the
sheltering facility and returning them to their evacuated location, including the costs of private
commercial carriers. The cost of ambulance services is eligible, but only after a licensed
physician has certified that an evacuee’s medical condition is likely to deteriorate if transported
by less costly means. Applicants must require the ambulance service to apply for
Medicare/Medicaid reimbursement for any situations that qualify for such assistance.
(e) Sheltering Costs. The reasonable and necessary costs incurred by the sheltering facility
directly related to the eligible activities in sections 4 and 5 of this document may be eligible for
reimbursement. Consumable and non-consumable supplies are eligible for FEMA
reimbursement only to the extent they exceed normal day-to-day usage in non-disaster
situations. Non medical staff compensation costs may be eligible but only for the additional
hours worked due to the increased patient population resulting from the SN evacuees.
(f)
Hospital Costs. In circumstances where a hospital is designated and used as a MN
Shelter, FEMA will reimburse the eligible costs of sheltering the evacuees under the provisions
and limitations of this policy, which includes the prohibition against reimbursement of medical
treatment costs. The sheltering costs discussed in this document are eligible only for evacuees
who are not admitted as hospital patients.
6/17/2017
APPENDIX E
LEVEL OF CARE TRIAGE MATRIX
Condition
General Shelter
Alzheimer ’s disease (ALZD)
Early
Ambulating Difficulty (walker,
cane, crutches)
Ameliorating Lateral Sclerosis
(ALS) wheelchair

Aphasia (communication
difficulty)
Arthritis
Self-ambulating
Asthma

Bronchitis

Cardiac
Cerebral Palsy
Stable, oral meds
Stable
Cerebrovascular Accident
(CVA)
Chronic Obstructive
Pulmonary Disease (COPD)
Colostomy
Comotose
Contagious, severe infection
Continuous Ambulatory
Peritoneal Dialysis(CAPD)
Cystic Fibrosis
Dementia
Diabetes/Hyperglycemia
Eating and Swallowing
Disorders
Edema
Examples
Medical Needs
Shelter
Moderate, cooperative,
Not a flight risk.
If other information
may indicate a need
Wheelchair bound,
able to transfer from chair
to bed

Medical Management Facility
Wheelchair bound,
able to transfer from
chair to bed
Requires nebulizer
treatments
If requires nebulizer
treatments
Controlled with Med.

Bed bound, requires pain
management
Wheelchair bound, able
to transfer from chair to
bed.
Oxygen Use
Advanced. Bedridden; nonverbal
Refusal to eat; totally dependent
Advanced, bedridden, totally
dependent
Unstable, requires urgent medical
evaluation, O2 sat below %
Unstable, requires urgent medical
evaluation, O2 sat below %
Unstable –Having SOB & Angina
Severe, bedridden, totally
dependent
Bedridden
Oxygen dependent, end stage

Assistance needed
Post surgical ostomy

Hepatitis, Tuberculosis, Measles
or mumps in adult

Stable
Needs meds
Able to follow
instructions, not a flight
risk
Insulin Administration
Assistant monitoring
Stable anorexia/bulimia
under treatment.
Swallowing disorders
requiring thickeners and
gastric feedings.
Related to mild CHF
and position
Respiratory Compromise
End stage, bedridden
Insulin and diet
controlled
Eating disorder
under control
 Mild, related to
position or non-acute
injury as in a sprain
American Red Cross
Evacuation Center
Emphysema
Not oxygen dependent
Foley Catheter
Stable
Fractured Bones

Special Needs Shelter
Oxygen use, minimal
monitoring
Management & Foley
Change
Pin site Care
Brittle diabetic, glucose over on
dialysis
No gag reflex, history of aspiration,
requires suction airway management
Acute CHF or other metabolic
condition requiring urgent medical
management
Medical Management Facility
Oxygen dependent, end stage
Catheter management post
surgical procedure
Acute injury requiring monitoring
6/17/2017
Dressing Changes
Monitor, assistance
with medications
<6 months
Requires assistance in
self-care
<6 months
G-Tubes
and pain management
Uncontrolled, requires urgent
medical management

Self-ambulating
Self-ambulating
Self-ambulating
Self-ambulating
Wheelchair bound
Wheelchair bound
Wheelchair bound
Wheelchair bound
Controlled
Controlled
Bed bound
Bed bound
Bed bound
Bed bound
Advanced
Uncontrolled

Controlled
Med Assistance
Needed
Open sores; draining,
dressing changes
High Blood Pressure/
Hypertension
Hip Replacement
Ileostomy
Stable
Knee replacement
Medical Equipment
Attachments
>6 months
Migraine Headaches
Multiple Sclerosis
Muscular Dystrophy
Neuromuscular Disorders
Osteoarthritis/Osteoporosis
Parkinson’s Disease
Psychosis
Respirator Ventilator
Dependent
Seizures
Skin Rashes
Sores/Non-Fluid
Sleep Apnea
Upper respiratory infection
Non-electric dependent

Isolation
Urinary Tract Infection
Wheelchair Transferable

Mobile with minimal
Assistance
Wheelchair bound with
Other conditions
>6 months

Recent surgical procedures
IV, NG –Tubes, Central Venous
CATHETERS OR
TRACHEOTOMY
Tube (newly placed or requires
frequent suctioning)
Uncontrolled
Infectious
Electric dependent, CPAP
Requires urgent medical evaluation,
Fever/O2 sat %
Bed bound
6/17/2017
ATTACHMENT F
MEDICAL NEEDS SHELTER
JOB ACTION SHEETS
State Managed Shelter – Public Health Services:
 Alternate Care Facility Unit Leader
 Medical Needs Shelter Medical Director
 Administrative Assistant
 Facility Manager
 Registration Assistant
 Triage Unit Leader
 Pharmacist
 Medical Needs Shelter Manager
 Nursing Staff
 Caregiver
 Emergency Medical Services
 Mental Health Staff
31
Alternate Care Facility Unit Leader
(Minimum of 1 per Shift)
Reports to: Operations Section Chief
Mission: Monitor the health status of the general shelter, medical needs shelter, and alternate care facility
populations, coordinate staffing and logistics for multiple facilities during an incident.
Qualifications: Experience with facility/clinic/shelter management.
Immediate:
 Read entire Job Action Sheet
 Initiate and maintain log of events and key actions
 Obtain briefing from Operations Section Chief
 Communicate your contact info (telephone, radio, pager, fax, etc.) to the
Section Chief
 Obtain the most current medical intelligence related to the conditions that are most likely to occur
as a result of the event, as well as relevant treatment
 Coordinate with SRHD and the Disaster Medical Hospital Control on prevention strategies and
anticipated disease control measures
 Assess staffing needs and availability
Intermediate:
 Ascertain resources needed by each MNS unit, and submit for procurement, transportation and
delivery of these resources including personnel, supplies and equipment, to the appropriate site
through the Logistics and Finance/Administration Section Chiefs
 Ascertain progress and status and of each Unit
 Immediately report to the Operations Section Chief conditions that are unsafe or situations that
are not improving or deteriorating
 Establish and maintain ongoing contact with Planning Section to coordinate data and analysis of
information
 Obtain up to date information from neighboring jurisdictions, including the CDC and state health
department
Extended:
 Brief Unified Command organization about status of operations activities on a regular basis
 Recommend and implement prevention strategies and disease control measures
 Observe staff for signs of stress and fatigue; assure provisions for staff rest and counseling
services
 Provide input for Situation Reports
 Provide in-briefing to relief shift
 Ensure all documentation collected for post-event evaluation and retention
32
Medical Needs Shelter Director
(Minimum of 1 per Shift)
Reports to: Operations Section Chief
Mission: Direct administration, coordination and delivery of health/medical services in the MNS.
Qualifications: Must have current medical license as a MD/PA/RN/ARNP with emergency care
experience. Retired providers with the Medical Reserve Corp (MRC) may be utilized if activated with a
current mission number.
Immediate:
 Read entire Job Action Sheet
 Initiate and maintain log of events and key actions
 Obtain briefing from Alternate Care Facility Unit Leader
 Ensure Job Action Sheets are disseminated to Medical Needs Shelter staff by Administrative
Assistant.
 Communicate your contact info (telephone, pager, radio, fax, etc.) to direct reports and to
management at SRHD, Medical Reserve Corp, American Red Cross, and the Disaster Medical
Hospital Control
 Review the Incident Action Plan (IAP); recommend specific Public Health measures and
determine the specific staff to be activated in order to achieve the mission
 Ensure appropriate staff is assigned to the MNS shelter.
 Provide direction to MNS staff; conduct periodic briefings
 Approve standard nursing protocols for the MNS staff;
 Approve all medical procedures performed at the MNS that are not covered by existing protocols,
recommendations or procedures;
 Provide diagnosis and treatment orders for acute illnesses that occur among residents of the MNS.
These are to be provided after attempts by nursing staff to contact the primary care physician are
unsuccessful;
 Consult with the Alternate Care Facility Unit Leader on resident care problems when required
and attempting to provide a resolution;
 Arrange professional contact each 24 hour period thereafter, if possible, to assess medical
problems at the MNS;
 Assure notification of available Medical Center’s on-call Emergency Room Attending Physician;
 Notify Disaster Medical Hospital Control that shelter is operational and relay relevant shelter
contact information; and
 Ensure telemedicine is operational where available.
Intermediate:
 Convene a meeting for all staff, communicate IAP and assign tasks
 Ascertain resources needed, and submit for procurement, transportation and delivery of these
resources including personnel, supplies and equipment, to the site through the Logistics and
Finance/Administration Section Chiefs
 Ascertain progress and status of the MNS
 Immediately report to the Alternate Care Facility Unit Leader conditions that are unsafe or
situations that are not improving or deteriorating
Extended:
 Observe staff for signs of stress and fatigue; assure provisions for staff rest and counseling
33




Provide input for Situation Reports
Provide in-briefing to relief shift
Ensure all documentation collected for post-event evaluation and retention
Assist in facility demobilization
34
Administrative Assistant
(Minimum of 1 per Dayshift)
Reports to: Medical Needs Shelter Director
Mission: Performs administrative duties as assigned and provides general support services for and with
Medical Needs Shelter staff.
Immediate:
 Read entire Job Action Sheet
 Initiate and maintain log of events and key actions
 Obtain briefing from Medical Needs Shelter Director
 Disseminate Job Action Sheets to Medical Needs Shelter staff.
 Provide safe, secure location to maintain all documentation that is collected
 Initiate list of residents, caregivers, staff and family members (confer with Medical Needs Shelter
Registration Assistant)
Intermediate:
 Report requests for information to the Medical Needs Shelter Director or appropriate Section
Chief
 Collect and maintain documentation in safe, secure location
 Maintain list of residents, caregivers, staff and family members (confer with Medical Needs
Shelter Registration Assistant)
 Help with basic comfort measures for residents (e.g. blankets, pillows) as you are able
 Maintain an orderly and clean area and dispose of trash
 Report any problems to the Medical Needs Shelter Director
 Help to maintain safety of the area
Extended:
 Provide support as requested to Medical Needs Shelter Director
 Provide input for Situation Reports
 Provide in-briefing to relief shift
 Ensure all documentation collected for post-event evaluation and retention
 Assist in facility demobilization
35
Facility Manager
(Minimum 1 per Shift)
Reports to: Medical Needs Shelter Director
Mission: Oversee the non-medical operation of the Medical Needs Shelter.
Immediate:
 Read entire Job Action Sheet
 Initiate and maintain log of events and key actions
 Obtain briefing from Medical Needs Shelter Director
 Become familiar with the building to be used: size, facilities, layout and supplies
 Confer with Medical Needs Shelter Director to assure adequate food supply for residents and
staff/volunteers
 Ensure food areas are kept clean and sanitary and that expiration dates and other safety
procedures are observed
 Attend shift briefings and report food service statistics, accomplishments, problems, and
recommendations
 Ensure that all residents, staff, volunteers and family members are registered upon arrival;
maintain a system for checking people in and out when they leave for any period of time
 Manage the system of record keeping for center registration; maintain and report daily census to
local Medical Needs Shelter Manager; and notify Medical Needs Shelter Manager when Medical
Needs Shelter is approaching 80% capacity
 Provide for information messaging services through Medical Needs Shelter Registration Assistant
 Ensure set up the registration area; and that all residents are registered
 Ensure signs designating the facility as an Medical Needs Shelter are posted
 Post signs that provide the name(s) of the person(s) in charge of the Medical Needs Shelter for
each shift (Medical Needs Shelter Manager and Medical Needs Shelter Director)
Intermediate:
 Supervise Registration Assistants and other non-medical shelter volunteers
 Maintain system for staff, residents and visitors to be checked in and out
 Maintain list of and keep accurate count of number of residents in the Medical Needs Shelter
 Provide information to residents and family members
 Recruit residents as volunteers and assign them to appropriate areas to assist with operations
Extended:
 Provide input for Situation Reports
 Provide in-briefing to relief shift
 Ensure all documentation collected for post-event evaluation and retention
 Assist in facility demobilization
36
Registration Assistant
(Minimum of 2 per Shift)
Reports to: Medical Needs Shelter Human Needs Manager
Mission: Oversee the registration and tracking of Medical Needs Shelter clients and visitors.
Immediate:
 Read entire Job Action Sheet
 Initiate and maintain log of events and key actions
 Obtain briefing from Medical Needs Shelter Director
 Set-up of Registration Area
a. Obtain needed supplies
 Intake forms
 Registration/information signs
 Administrative Supplies, e.g., pens/pencils
b. Post the following:
 Interior signs
 Exterior signs
 Medical Needs Shelter rules
 Register individuals as they come into the Medical Needs Shelter
a. Fill out a blank registration form
b. Once all of the Residents are registered, provide information, register any visitors, complete a
tally, and organize paperwork
 Give residents brief orientation to the Medical Needs Shelter
Intermediate:
 Provide assistance and information to residents, family members and visitors as they sign in
 Alphabetize and organize all registration information and maintain count of all persons in the
Medical Needs Shelter
 Log all activity either on a needs medical update for or in the medical log
 Participate in the non-health/medical briefings at the beginning and ending of each shift
 Maintain ongoing accountability of incoming and outgoing persons
Extended:
 Provide input for Situation Reports
 Provide in-briefing to relief shift
 Ensure that all registration materials and records of residents are gathered, stored in a secure
location, and ready to ship
 Gather up and re-inventory all supplies
 Collect all paperwork, supplies, and signs and help pack the items for removal
 Pack medical records/medical logs
 Ensure all documentation collected for post-event evaluation and retention
 Assist in facility demobilization
37
Triage Unit Leader
(Minimum of 1 per Shift)
Reports to: Medical Needs Shelter Director
Mission: Screen clients to determine acute and chronic medical needs.
Qualifications: Must have a current license as a Registered Nurse or Nurse Practitioner.
Immediate:
 Read entire Job Action Sheet
 Initiate and maintain log of events and key actions
 Obtain Briefing from Medical Needs Shelter Director
 Communicate your contact info (telephone, radio, pager, fax, etc.) to the
Director
 Interview clients and complete appropriate forms
 Conduct visual evaluation of registrants
Intermediate:
 Refer client to acute/primary care as deemed necessary
 Oversee the work of other personnel as it relates to screening
 Evaluate needs and report requests through the Medical Needs Shelter Director to Operations
Chief
 Coordinate with other services as needed
Extended:
 Monitor supplies to ensure there is a sufficient amount
 Prepare end of shift report for outgoing/incoming Medical Needs Shelter Director
 Provide input for Situation Reports
 Provide in-briefing to relief shift
 Ensure all documentation collected for post-event evaluation and retention
 Assist in facility demobilization
38
Pharmacist
(Minimum of 1 per Dayshift)
Reports to: Medical Needs Shelter Director
Mission: Arrange for and administer pharmacy services to the Medical Needs Shelter.
Qualifications: Must be a licensed pharmacist.
Immediate:
 Read entire Job Action Sheet
 Initiate and maintain log of events and key actions
 Obtain briefing from Medical Needs Shelter Director
 Maintain updated lists of inventory (medical supplies and nonprescription medications) for
shelter
 Verify appropriate secured space for supplies, as needed. Items requiring refrigeration are to be
stored in a secured refrigerator with access allowed only to shelter staff.
 Document/maintain log of pertinent events and incidents.
 Contact pharmacy chain organizations who have mobile pharmacies as well as participating local
pharmacies to advise them about the situation, the possible needs and ask them to maintain a
stand-by status. Keep these groups advised throughout the process.
 Determine as soon as possible whether mobile pharmacies should be requested and if so, how
many and to which locations. Alert the participating pharmacy chains as well as local pharmacies.
 Mobilize all staff that will be assisting in pharmacy services at the shelters, including triage
officers and any support staff.
 If an inventory of medical supplies and nonprescription drugs are to be available at shelters, they
should be ordered. Request assistance through Alternate Care Facility Unit Leader to Spokane
Emergency Coordination Center.
 When information about participating mobile pharmacies is known, devise an initial plan for
coordinating services among the mobile pharmacies and local pharmacies and advise all
participants.
 As evacuees needing pharmacy services arrive, the Triage Unit Leader shall be available at a
designated area and adhere to the following procedures for prescription needs:
 Patients with all required information for refills will be directed to the mobile pharmacy or to
transportation to local pharmacies.
 For patients who do not possess all of the required information, but it can be obtained through
third parties; the triage officer will obtain this and give a copy to the patient who will be
directed to the mobile pharmacy or to transportation to local pharmacies.
 Patients who do not possess all of the required information or when the information cannot be
obtained and patients who need medical assessment and/or treatment will be directed to the
shelter physician.
 As shelterees have needs for nonprescription medications and medical supplies, the Triage Unit
Leader or assistant will make the decision or refer the request to a physician. These will either be
obtained from the stock in the shelter, the mobile pharmacy or ordered for delivery.
 If the patient's request is for syringes, needles, or exempt narcotics, the request will be evaluated
by the Triage Unit Leader and sent to the physician for evaluation. Prescriptions will be written
for appropriate requests.
Intermediate:
39
 Continue coordinating services among the mobile pharmacies and local pharmacies, adjusting as
conditions change.
 Evaluate continued adequacy of medical supplies and non-prescription drugs on hand and order
supplies as needed. Emergency needs will be ordered immediately, while other requests will be
gathered, combined, and ordered periodically
Extended:
 Provide input for Situation Reports
 Brief with Medical Needs Shelter Director, Triage Unit Leader and any other related staff at the
beginning and end of each shift to delineate the triage procedures to be followed
 Provide in-briefing to relief shift
 When the shelter is deactivated, all remaining medications and medical supplies should be
collected. When possible, unopened factory-sealed containers should be returned for credit and
opened containers should be properly disposed.
 Ensure all documentation collected for post-event evaluation and retention
 Assist in facility demobilization
40
Medical Needs Shelter Manager
(Minimum 1 per Shift)
Reports to: Medical Needs Shelter Director
Mission: Provide oversight for all clinical services. Ensure clinical staff performs only those activities
consistent with his or her level of expertise.
Qualifications: Must have a current license as a MD, PA, RN or ARNP.
Immediate:
 Read entire Job Action Sheet
 Initiate and maintain log of events and key actions
 Obtain briefing from Medical Needs Shelter Director
 Oversee the activation of the health/medical operation of the MNS, including the use of
procedures, selection of treatment areas, and the receipt, storage, and disbursement of medical
supplies
 Become familiar with the building to be used; its size, facilities, layout and available supplies
 Assure triage of individuals brought to the Medical Needs Shelter who have health and medical
problems to determine their most appropriate placement
 Refer individuals to hospitals and skilled nursing facilities if necessary, working through the
Medical Needs Shelter Director and EMS
 Determine the number of staff needed to provide care to residents based on the actual number and
needs of those residents and maintain a daily census
 Assess the health care needs of the Medical Needs Shelter residents who are not acutely ill and
ensure implementation of the orders by the nursing staff
 Arrange area for safe, secure storage of medical supplies
 Have area set up where persons can come for medical assistance – refer to facility layout in this
Plan for pre-determined location:
o First Aid Station
o First Aid kit
o Other medical supplies
o Medical forms
o First Aid Station sign
o Pens/pencils/other needed office supplies
o Medical activity log
o Place medical supplies in a safe, lockable area and inventory all items
Intermediate:
 Supervise the health care delivery services of the nursing staff :
o Assess nursing staff needs (see Recommended Staffing Ratios section of this Plan) and
modify as appropriate
o Experienced caregivers including certified nursing assistants (CNA), personal care attendants,
nursing aides, home health aides, companions, emergency medical personnel, medical or
nursing students, and orderlies may assist in providing care under the supervision of an RN
o Volunteers may assist in providing care to the residents; however, they must do so under the
supervision of the Medical Needs Shelter Manager
 Ensure approved protocols are utilized by nursing staff
 Ensure that all allied health program students and support staff have appropriate supervision
 Provide administrative and logistical support to the nursing staff
41
 Prepare supply orders for medications and assuring proper utilization of all supplies
 Monitor potential for infectious disease transmission and communicate with Public Health
Surveillance Team.
 Evaluate staff for signs and symptoms of stress reaction and poor coping; lead the health/medical
briefings conducted at the beginning and ending of each shift;
Extended:
 Provide input for Situation Reports
 Participate in briefings at the beginning and end of each shift
 Provide in-briefing to relief shift
 Establish and implement discharge process in consultation with the Medical Needs Shelter
Director and clinical staff
 Ensure retention and disposition of medical records to appropriate authority after consult with the
Medical Needs Shelter Director and clinical staff
 Ensure all documentation collected for post-event evaluation and retention
 Assist in facility demobilization
42
Nursing Staff
(Minimum 4 per Dayshift, 2 per Nightshift)
Reports to: Medical Needs Shelter Manager
Mission: Deliver appropriate health/medical services within the Medical Needs Shelter under the
direction of the Medical Needs Shelter Manager.
Qualifications: Licensed Registered Nurse or Licensed Practical Nurse
Immediate:
 Read entire Job Action Sheet
 Initiate and maintain log of events and key actions
 Obtain briefing from Medical Need Shelter Manager
 Supervise and assist in the administration of medications to the residents
 Deliver care and assistance to residents as required following approved protocols, procedures, and
recommendations
Intermediate:
 Assess the physical condition of the residents on an on-going basis
 Maintain the resident’s medical update form and advise the Medical Needs Shelter Manager of
any adverse change in the condition of a resident
 Monitor those residents who are receiving oxygen and refer to respiratory therapist or other
appropriate resource if problems occur
 Observe shelterees to assure they meet the MNS admission criteria. Send people who do not
meet the Medical Needs Shelter admission criteria to the general shelter. Confer with Medical
Needs Shelter Manager on those who should receive skilled care in a hospital or nursing home
environment
 Refer persons who need immediate medical attention to EMS
 Determine where residents should be placed in the Medical Needs Shelter
 Maintain standard precautions and infection control
Extended:
 Provide input for Situation Reports
 Participate in briefings at the beginning and end of each shift.
 Provide in-briefing to relief shift
 Establish and implement discharge process in consultation with the Medical Needs Shelter
Manager
 Ensure retention and disposition of medical records to appropriate authority after consult with the
Medical Needs Shelter Manager
 Ensure all documentation collected for post-event evaluation and retention
 Assist in facility demobilization
43
Caregiver
(Minimum 6 per Dayshift, 6 per Nightshift)
Reports to: Medical Needs Shelter Manager
Mission: Deliver appropriate health/medical services within the Medical Needs Shelter under the
direction of the Medical Needs Shelter Manager or nursing staff.
Qualifications: Caregivers and other supplemental non-allied health professionals, including family
members or significant others working under the direction of the nursing staff, assist the Nursing Staff in
caring for shelterees.
Immediate:
 Read entire Job Action Sheet
 Obtain briefing from Medical Need Shelter Manager
 Deliver care and assistance to resident as required following approved protocols, procedures, and
recommendations
Intermediate:
 Assist residents with mobility impairments in ambulation and transfer
 Assist the nursing staff as requested
 Keep the residents as calm as possible
 Monitor resident conditions for changes and immediately report to the nursing staff
 Work within license or certification, or skills and abilities
 Follow directions of licensed staff person in charge
 Report particular needs of residents to the Nursing staff
 Assist residents with getting settled in their space and answering questions regarding location of
bathroom, meals, etc.
 Assist in ambulating, toileting, transfers and personal hygiene
 Keep residents aware of time and inquiring if assistance is needed with self-administered
medications and treatments; obtain assistance from Nursing Staff if help is needed;
 Provide diversion activities, conversation, etc.
 Assist in acquiring food and/or feeding as needed
 Assist in keeping area clean and free of trash
 Maintain standard precautions and infection control
Extended:
 Provide input for Situation Reports
 Participate in briefings at the beginning and end of each shift.
 Provide in-briefing to relief shift
 Assist in resident discharge process when requested by Nursing Staff
 Provide any documents or medical records to Nursing Staff prior to resident discharge
 Assist in transfer of resident to transportation services when they are ready to leave the facility
 Ensure residents are signed out
 Ensure all documentation collected for post-event evaluation and retention
 Assist in facility demobilization
44
Emergency Medical Services
(Minimum of 2 per Shift)
Reports to: Medical Needs Shelter Director
Mission: Provide assistance to the facility as it relates to the administration of resident first aid and
emergency medical treatment needs, and transportation of patients to medical provider facilities when
transportation services are required.
Qualifications: Must have a current license as an EMT-Basic, Enhanced, Intermediate, Shock Trauma or
Paramedic.
Immediate:
 Read entire Job Action Sheet
 Initiate and maintain log of events and actions
 Obtain briefing from Medical Needs Shelter Director
 Confer with Medical Needs Shelter Manager on immediate EMS support needs
Intermediate:
 Provide emergency medical assistance as needed
 Periodically confer with Medical Needs Shelter Manager on ongoing EMS support activities
 Assist nursing staff as requested
 Oversee transport of Medical Needs Shelter residents via ambulance to hospital, nursing home or
assisted living facility, as required
Extended:
 Provide input for Situation Reports
 Participate in briefings at the beginning and end of each shift.
 Provide in-briefing to relief shift
 Ensure equipment is accounted for and returned to proper storage/staging location(s)
 Ensure all documentation collected for post-event evaluation and retention
 Assist in facility demobilization
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Mental Health Staff
(Minimum of 2 per Shift)
Reports to: Medical Needs Shelter Director
Mission: Provide mental/behavioral health services, e.g., crisis, bereavement and traumatic grief
counseling services, to shelter residents.
Qualifications: Must be at minimum a licensed mental health/crisis counselor.
Immediate:
 Read entire Jog Action Sheet
 Initiate and maintain log of events and actions
 Obtain briefing from Medical Needs Shelter Director
 Confer with Medical Needs Shelter Manager on immediate resident mental/behavioral health
needs
Intermediate:
 Make rounds watching for signs of agitation, depression, or confusion, and resolve potential
problems
 Assist the staff in promoting diversions and activities, conversation, time orientation
 Work with the residents who are experiencing mental health problems and guide the staff on how
to be most therapeutic in the situation
 Report current problems and potential problems that may need additional intervention to the
Medical Needs Shelter Manager
Extended:
 Provide input for Situation Reports
 Participate in briefings at the beginning and end of each shift.
 Provide in-briefing to relief shift
 Develop plan for debriefing/counseling of shelter staff before demobilization
 Develop plan for follow-on counseling of staff and shelter residents, if needed, following facility
demobilization
 Ensure all documentation collected for post-event evaluation and retention
 Assist in facility demobilization
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ATTACHMENT G
FORMS
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ARC Initial Intake and Assessment Tool
http://www.acf.hhs.gov/ohsepr/snp/docs/disaster_shelter_initial_intake_tool.pdf
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APPENDIX H
COMMON DEFINITIONS & ACRONYMS
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Caregivers – Experienced caregivers include certified nursing assistants, personal care
attendants, nursing aides, home health aides and/or companions. In addition, caregivers may
be family members. The expectation is that caregivers will accompany medically fragile
persons to shelter sites and maintain the continuity of care at the shelter facility.
Companion animals - A domesticated animal, such as a dog, cat, bird, fish or rodent that is
traditionally kept in the home for pleasure rather than for commercial purposes.
ECC – Emergency Coordination Center
ED - Emergency Department
EMS - Emergency Medical System
EMT - Emergency Medical Technician
ICS – Incident Command System
LPM – Licensed Practical Nurse
NEHC – Neighborhood Emergency Help Center
NP – Nurse Practitioner
PPE – Personal Protective Equipment
RN – Registered Nurse
Service animals - Any guide dog, signal dog, or other animal individually trained to provide
assistance to an individual with a disability.
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APPENDIX I
REFERENCES
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Shelter Operations Management Toolkit: Operational Tips, Checklists and Best Practices for
Shelter Managers, http://www.fema.gov/pdf/emergency/disasterhousing/dspg-MCShelteringHandbook.pdf
California Government-Authorized Alternate Care Site Training Guide,
http://bepreparedcalifornia.ca.gov/NR/rdonlyres/9803A6E4-888E-420A-9B4F478D77362511/0/CDPH_ACS_Training_Guide.pdf
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