Download Emergency Operations Plan

FirstHealth of the Carolinas
Emergency Management
(EM.01.01.01 – EM.03.01.03)
Emergency Operations Plan
Original - August 5, 2008
PRINCIPLES OF THE FIRSTHEALTH OF THE CAROLINAS
EMERGENCY OPERATIONS PLAN
FirstHealth of the Carolinas (FHC) emergency operations plan is conceived and designed to
respond to a single and multiple emergencies for an extended length of time without reliance on
community support when an extended emergency should occur.
FHC uses the information from assessments (HVA, and the six critical areas of emergency
management) to develop our Emergency Operations Plan, which are tested regularly, and uses
the lessons learned to improve.
FHC can not predict the nature of a future emergency that may occur, nor can it predict the date
of its arrival. Therefore, FHC has planned for managing the six critical areas of emergency
response so that it can assess needs and prepare staff to respond to events most likely to occur,
regardless of causes of emergency situations. The six critical areas of managing an emergency
that FHC plans for are as follows;
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Communication (EM.02.02.01) FHC has developed a plan to maintain communication
pathways both within the hospital and to critical community resources.
Resources and assets (EM.02.02.03) FHC has established access to in times of crisis in
order to ensure patient safety and sustain care, treatment, and services.
Safety and security (EM.02.02.05) As emergency situations develop and parameters of
operability shift, FHC provides a safe and secure environment for their patients, visitors
and staff.
Staff responsibilities (EM.02.02.07) FHC has developed alternate roles from the
Emergency Management Staffing Risk Assessment (See Appendix C for matrix) to
ensure that staff can adapt to their new roles and responsibilities during an emergency
and as an emergency situation escalates.
Utilities management (EM.02.02.09) FHC has inventoried all of its essential utilities
based on calculated demand loads that may be imposed in an emergency condition and is
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prepared to maintain effective operations of the hospital and strive for 96 hours without
reliance for replenishment of supplies associated with utilities at FHC from external
sources.
Patient clinical and support activities (EM.02.02.11) FHC has a clear and reasonable
plan in place to address the needs of patients during extreme conditions when FHC
infrastructure and resources are taxed.
This emergency operations and management plan is supported by additional documentation
contained in the plan as an appendix as follows:
 Appendix A: Hazard Vulnerability Analysis
 Appendix B: Emergency Operations Plan – Four Phase Planning Activities
 Appendix C: Emergency Operations Plan – Assets and Resource Inventories
 Appendix D: Alternative Sites for patients care, treatment and services during
emergencies
 Appendix E: Coordination Matrix for the 6 critical areas of emergency
management
 Appendix F: Incident Command Structure
1.0
PROGRAM OBJECTIVES
It is the intent of the Emergency Operations Plan to describe FHC’s emergency preparedness
program and ensure an effective response to a variety of natural, human and technological
disasters that could cause harm and/or disrupt the environment of care. The plan provides distinct
policy direction, describes the roles and responsibilities of personnel and contains information
and references to corresponding departmental mitigation, preparedness, response, and recovery
procedures.
2.0
SCOPE
The Emergency Operations Plan applies to natural, human and technological events that
significantly disrupt the environment of care and treatment (i.e. hurricane, loss of utilities, civil
disturbance, act of terrorism, etc.); or that results in sudden, significantly changed, or increased
demands for the organization’s services (i.e., bioterrorist attach, building collapse, plane crash,
etc.).
3.0
PROGRAM ORGANIZATION AND RESPONSIBILITIES
1. FHC’s Board of Directors and Administrative teams provide the program vision,
leadership, support and appropriate resources, which are embodied within and conveyed
through the development and institutionalizing of business fundamentals relative to
emergency management.
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2. FHC Safety Committee
The Board of Directors and Administrative Teams have given the FHC Safety Committee the
authority to ensure that the emergency operations plan is formulated, appropriately set forth and
carried out. The FHC Safety Committee monitors the ongoing program and provides a forum for
consensus building, approvals, recommendations for improvements and exercise planning to the
Corporate Disaster Committee. The FHC Safety Committee serves as the central hub of the
information collection and evaluation and furnishes a forum to ensure pertinent action items,
issues, and risks are controlled in a timely fashion. The FHC Safety Committee receives reports
from the Disaster and examines the actions taken relative to the emergency operations plan.
Recommendations are given to and received by the Disaster Committee.
3. Corporate Disaster Committee
The FHC Safety Committee has delegated the management of the emergency management
program’s policies and procedures to the Corporate Disaster Committee. The Corporate
Disaster Committee is multi-disciplinary in nature, integrating key functional areas, including
Human Resources, Facilities/Engineering, Medical Staff, Quality/Clinical Performance,
Clinical Operations, Emergency Medical Services, Security and Leadership. Functions of the
Corporate Disaster Committee include designing, conducting and evaluating disaster drills
and exercises; proposing and reviewing policies and operational procedures; reviewing and
recommending revisions to the emergency operations plan; and annual evaluation of the
overall emergency preparedness program. Corporate Disaster Committee reports are given to
the Corporate Safety Committee for Quality/Clinical Performance review.
4. Safety Officers
The Director of Safety is the Corporate Disaster Committee Leader and has the authority and
responsibility for strategic design and the operational oversight of the Emergency Operations
Plan with input from each entity’s Safety Officer. The Safety Officer’s responsibilities
include:
A. Providing overall coordination as appropriate of the emergency operations plan
B. Developing the facility disaster plan
C. Providing guidance and technical assistance to departments for department specific
planning
D. Responding to disasters and coordinating drills
E. Reporting and evaluating incidents, drills and exercises
F. Coordinating specialized emergency preparedness training.
The Safety Officer also works in concert with Administration, the Corporate Disaster
Committee, and the FHC Safety Committee to ensure the Emergency Management program is
in alignment with the direction of the comprehensive Environment of Care program. The Safety
Officer compiles relevant information to form the basis of periodic reports to the FHC Safety
Committee and to the Quality/ Clinical Performance Committee.
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5. Quality/Clinical Performance Committee
FHC’s Quality/ Clinical Performance Committee is primarily focused on patient safety
initiatives and oversees the hospital’s “Plan for Patient Safety”. The Safety Officer as
appropriate meets with the Quality/ Clinical Performance Committee and participates in
initiatives to provide a safe environment of care to patients, including but not limited to issues
pertaining to disaster preparedness. Efforts to minimize the risk to patients in the event of a
disaster are communicated to the Quality/ Clinical Performance Committee through disaster
drill critiques, HVA review, and periodic performance reports.
6. Department Director
Each Department Director, or designee, is responsible for the provision of a safe work
environment for his/her staff and safe, suitable provisions for the care of patients, through
full implementation of established emergency management programs. Directors are also
responsible for the development and management of specific department disaster policies and
procedures (as applicable), ensuring that they are evaluated and revised (as appropriate),
verifying all staff are trained on their individual roles and responsibilities. The Department
Director is responsible for ensuring the department specific disaster policies are consistent
with the emergency operations plan; and staff participates in the implementation of the plan.
7. Employees
Employees are responsible to participate in emergency management training and exercises,
as well as to demonstrate core competencies in the given subject matter. Employees must
ensure their behaviors, work practices and operations are safe, and in accordance with
departmental procedures, the provisions of the disaster plan, and clinical judgment.
4.0
PROGRAM IMPLEMENTATION AND PROCESSES
FHC PLANS FOR MANAGING THE CONSEQUENCES OF
EMERGENCIES (EM.01.01.01)
1. Active Participation in Emergency Planning
Representation from leadership and the medical staff at FHC actively participate in
emergency management planning by attending disaster committee meetings and reviewing
strategies set forth by the organization in response to emergencies.
2. Hazard Vulnerability Analysis (HVA)
The risk to the hospital of naturally occurring events, technological events, human related
events as well as events involving hazardous materials has been calculated as part of the
HVA to indicate the potential emergencies that could have either a direct or indirect effect on
FHC operations and demand for services. Risks associated with large scale emergency
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events are periodically reviewed and analyzed by the Safety Officer in concert with
Administration and the local geographic area (i.e. Moore, Montgomery and Richmond
Counties). When conducting the risk assessment of the hospital the probability of the event
happening, as well as the severity of the impact of a potential event was taken into
consideration. Each FHC hospital has consulted with local emergency management
planners for the purpose of prioritizing disaster preparedness efforts. The staff and our
community are continually reminded of response procedures for prioritized events through
education, drills, and training.
Each entity’s HVA is evaluated annually relative to its objectives, scope, performance, and
effectiveness. This evaluation process is coordinated through the Safety Officers, in
conjunction with each entity’s Safety Committee, as appropriate.
3. Coordination with Community
A. FHC Hospitals Role in Community Emergency Management Program: FHC hospitals
participate in several community wide emergency management programs, such as the
local emergency planning committee (LEPC) of Moore, Montgomery and Richmond
Counties, the Mid Carolina RAC (MCRAC), Disaster Preparedness Personnel Response
(DPPR) and National Disaster Medical System (NDMS). FHC’s role in relation to these
entities in the event of a disaster is discussed, planned, and exercised accordingly.
B. An “All-Hazards” Command Structure that Links with the Community’s Command
Structure: The Hospital Incident Command System (HICS) model is in direct
correlation with Moore, Montgomery and Richmond Counties EOC, Fire Department
ICS, Police Department ICS, as well as neighboring hospital HICS structures.
C. Communicating the Hospital’s needs and Vulnerabilities: FHC has met with the local
emergency planning committee (LEPC) of Moore, Montgomery and Richmond Counties,
the Mid Carolina RAC (MCRAC), Disaster Preparedness Personnel Response (DPPR)
and National Disaster Medical System (NDMS) and communicated the hospital’s needs
and vulnerabilities based on analysis conducted as part of the FHC’s emergency
operations plan and established expectations that the hospital will have from local
response agencies in a disaster in terms of the local response agencies meeting the needs
of the hospital.
4. The disaster policies and procedures are developed through the Safety Officers in
concert with the appropriate committees.
The Code Triage - Disaster Plan outlines the following levels of an emergency:
 Normal Operations – Involves a moderate incident that may or may not warrant
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Code Triage activation, as local resources are available and adequate.
Code Triage Stand By (Alert) - Defined as an extraordinary situation managed
within the Emergency Department (ED) with pre-existing manpower and supplies.
Emergency response levels are determined by the Emergency Physician and Clinical
Director/designee.
 Code Triage – (Emergency Operations Plan Activated) – Defined as a situation
that necessitates hospital-wide involvement and resources. Plan of activation and
deactivation is performed by the Emergency Department Physician and Clinical
Director/designee
 CODE TRIAGE DECON TEAM – (Emergency Operations Plan activated)
Defined as a event of a chemical or biological situation managed within the
Emergency Department (ED) with pre-existing manpower and supplies or
necessitates hospital-wide involvement and resources. Plan of activation and
deactivation is performed by the Emergency Department Physician and Clinical
Director/designee. (Refer to departmental procedures in the Decontamination Plan).
 All Clear – Operations of the area or hospital have returned to normal or near normal
status. Implement recovery processes, as necessary.
Full implementation and training on department specific procedures are assured at the
department level by the Department Director.

5.
Development of Emergency Operations Plan
FHC Emergency Operations Plan is based upon the industry standard of HICS as a
coordinated organizational response to a disaster. In addition to utilizing this industry
standard, FHC disaster planning involves the incorporation of the principles of the plan into
all levels of the organization. Specific policies and procedures are developed in collaboration
with FHC Administration, physicians, and front-line staff.
6. Mitigation, Preparedness, Response, and Recovery
Emergencies will occur. Effective assessment and planning reduces the impact of
emergencies on the quality of patient care. The FHC EOP is based on, and addresses the four
phases of the plan
A.
Mitigation
This phase of emergency management involves proactive efforts to minimize the severity
and impact of a potential disaster and reduce the potential for an event to occur. Pursuant
to the results of risk assessments, the Safety Officers will assist with the identification
and implementation of appropriate mitigation efforts.
B.
Preparedness
This aspect of the emergency management planning process refers to activities and plans
designed to increase readiness, should disaster response become necessary. The Safety
Officers, in conjunction with the Disaster and Safety Committees, coordinates
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preparedness efforts to identify resources that may be used if an emergency occurs. All
departments are responsible to actively participate in preparedness efforts, to the extent
that the unique departmental risks are addressed and program continuity is maintained
throughout the facility.
C. Response
This phase focuses on tactical activities and actions taken to address a disaster event, to
include the implementation of one or more component of the emergency operations plan.
The IC/ACC guides and directs the overall response, forecasting and strategic planning at
the time of an incident. As indicated or directed, all departments are expected to
implement appropriate aspect of the plan.
D. Recovery
This phase entails those efforts to quickly and effectively re-establish business, resume
critical support functions, continue the provision of care, and ensure financial integrity.
The Recovery aspects of the plan take the form of risk and vulnerability analysis that
include contingency plans and interim measures that are predicated on relative risks,
resources and systems operations; efforts to identify and quantify shortfall of damages
and outlay for the purposes of reimbursements and governmental interventions, as
indicated.
9. FHC maintains a documented inventory of assets and resources on-hand, that is available on
site for use in an emergency. This inventory is updated on an on-going basis, and full
inventory assessment and review is completed at least annually. Through this assessment the
organization can identify its capabilities to be self-sustaining in the event that FHC cannot be
supported by our local community for 96 hours. Once the plan is activated, supplies and
equipment availability is closely monitored for depletion and replenishment. Supply
conservation activities may be required, and this will be done at the direction of the Logistics
Chief in collaboration with other members of the General and Command Staff. This
inventory includes but is not strictly limited to PPE’S, water, fuel, staffing, medical / surgical
supplies, pharmaceuticals and other back-up supplies listed in appendix C.
10. FHC has established a method for monitoring quantities of assets and resources during an
emergency and keeps control of depletions of supplies in order to assess duration of
sustainability for an extended emergency (see appendix C for asset and resources
monitoring).
11. Annual Evaluation of Emergency Management Planning
On an annual basis, Emergency Management Planning will be evaluated relative to its
objectives, scope, performance, and effectiveness
A report will be given to each entity’s Safety Committee and then reported to Quality/
Clinical Performance and then to the Board of Trustees/ Directors for review. In addition, the
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HVA will be reviewed annually to determine whether it needs to be changed or altered due to
disaster drill findings, staff knowledge, and change in current events.
FHC DEVELOPED AND MAINTAINS A WRITTEN EMERGENCY
OPERATIONS PLAN (EOP) THAT DESCRIBES AN “ALL- HAZARD”
COMMAND STRUCTURE (EM.02.02.01)
The EOP provides processes for initiating the response and recovery phases of identified
emergency situations. Based on the damage assessment and evaluation of operational
needs, an incident recovery plan will be developed and implemented immediately. The
Incident Commander/Designee is responsible for initiating this activity. The EOP is based
on an “all-hazard” command structure for coordinating the six critical areas of operations
as follows;
FHC ESTABLISHES EMERGENCY COMMUNICATIONS STRATEGIES
(EM.02.02.01)
1.
Notification and reporting (Personnel, Medical Staff, Agencies) when emergency
measures are initiated:
The Department Director’s or designee’s responsibility is to continually assess and adjust
staffing patterns so as not to exceed the individual capability of the staff utilized during a
disaster.
A.
MEDICAL STAFF
Notification:
The Medical/Technical Specialist, in collaboration with the Emergency
Department Physician (if not Unit Leader), will notify the Medical Staff.
The Medical Staff office will also respond to requests for telephone numbers and
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specialties of physicians.
Exception:
On call Emergency Department Medical Staff
shall be notified by the Emergency Department
Charge Nurse/Designee as requested by the
Emergency Department Physician.
NOTE:
In the event of significant road closures, a designated
physician staging area will be arranged and located at the
site or where designated if needed.
Reporting:
With or without notification and after family and home are secured, all
physicians are to report to the Medical Staff Personnel Pool, in the Medical
Staff Office, or where designated, for assignment. Physicians will be assigned, as
needed, by the Medical Staff Director Unit Leader or designee.
Exception:
B.
On-Call Emergency Department Medical Staff shall
report directly to the Emergency Department.
PERSONNEL
Notification:
When the hospital activates its Emergency Operations Plan (EOP), Department
Directors or Designees will be notified by telephone or runner or overhead page.
They will be informed of the type of disaster and an estimate of the number and
type of patients to be expected. Each Department Director, or designee, will
activate their Departmental Disaster Plan to the degree that is necessary. If a
department is closed, the appropriate Department Director or Designee will be
instructed to implement their telephone tree, if necessary.
Reporting:
All off duty employees should report initially to the Personnel Pool.
Moore Regional Hospital – Cafeteria
Richmond Memorial Hospital- Cafeteria
Montgomery Memorial Hospital- 2nd Floor Nursing Station
C.
VOLUNTEERS
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Notification:
The Director of Volunteer Services, or designee, will be notified by the Planning
Section Chief/Designee and will then initiate their departmental plan to provide
staff.
Reporting:
Volunteers will report to the Volunteer Services Office or other designated
location and sign in.
D.
CHILDREN OF EMPLOYEES
If employees do not have care facilities for their children they may bring them to
the designated child care location if needed. The need for a Child Care Center
will be reassessed every eight (8) hours by the Director, Child Development
Center/designee.
E.
FIRE AND POLICE DEPARTMENT
The Fire Department is contacted automatically through the fire alarm system for
fire situations.
For non-fire situations, the Incident Commander/ Designee as appropriate will
contact Fire and/or Police Departments.
F.
FAMILY, VISITORS, CLERGY
Will be routed to the hospital’s family waiting area. All entrance doors to the
hospital will be secured by security as needed except the main entrance and the
Emergency Department entrance if lockdown procedures are initiated by the
IC/ACC.
G.
PRESS AND MEDIA
Staff members should contact the IC/ACC when approached by a member of the
press or media. Staff members should not give information to the press or media.
All information will be provided by the Public Information Officer (PIO).
In a major event members of the press/media will be escorted to the designated
area where a Public Information Center will be established.
2. On going communication of information and instruction to staff once emergency
measures are initiated:
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On going communication and dissemination of information to staff is of vital importance
during a disaster it enables better utilization of assets and resources. During a disaster all
information and communications will be funneled through the section leaders to the incident
commander then disseminated back to the section leaders for communicating to the
individual department directors.
3. Processes and Plans for communicating with external authorities once emergency
response measures are initiated:
FHC participates in community wide emergency management planning groups. This group
of hospital and community emergency management planners has agreed to provide mutual
aid to one another in the event of a disaster. Also included in the disaster planning is the
sharing of the following information to improve communication and resource management
when responding to a disaster:
A.
B.
C.
D.
Essential elements of command structures and control centers for emergency response
Names, roles, and telephone numbers of individuals in their command structures
Resources and assets that could potentially be shared or pooled in an emergency response
Names of patients and deceased individuals brought to their organizations to facilitate
identification and location of victims of the emergency.
Several local agencies may play a role in managing an emergency. Some of the key contacts
include police, fire, EMS, local emergency management offices, department of Health, CDC
and the Red Cross. Agencies are notified by the Incident Commander or a designee as soon
as possible after an emergency response is initiated.
Communication with external agencies will depend on the given emergency situation. For
example, as outlined in the Bioterrorism Plan, evidence of a possible biological attack will be
reported to the Moore, Richmond, or Montgomery Public Health Care Agency, Emergency
Medical Services (EMS), local police department, and if verified, to the State of North
Carolina Department of Health & Human Services, FBI Field Office, and CDC.
When all normal communication channels (telephone, cell phones and emails) are operative,
the normal means of voice / electronic communications is the first to be sought. When
normal communication channels are not operative (due to internal or external infrastructure
damage, loss of power or loss of communications links; wiring, satellite, microwave
transmissions), the hospital will use all available means to communicate with external
authorities including employment of walkie-talkie radios, ham radios, and runners.
5. Communication with patients and their families during emergencies and notification of
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patient relocation to alternate care sites:
FHC staff will communicate with patients during disaster response and Code Triage activities
in order to allay their anxieties. It is essential that the patients understand the reasons for the
accelerated activities they notice, and be reassured. For patients whose family was not able to
arrive at the hospital prior to an emergency in the community or the hospital, designated staff
will contact family members to inform them of the conditions of their loved ones and the
emergency response activities. If the hospital can no longer sustain operations and relocation
of patients becomes necessary; designated staff will notify family members (those present at
the hospital and those unable to get to the hospital due to the nature of the emergency in the
community) that their loved ones are being relocated and provide the name of the facility
where the patient is being relocated and provide name and telephone number of contact
individual at the facility.
6. FHC defines the circumstances and plans for communicating with the community and
the media during emergencies:
When the emergency operations plan is initiated at the hospital, the hospitals will
communicate with external agencies depending on the given emergency situation. Reporting
requirements are included in the specific disaster response policy and procedure. For
example, as outlined in the Bioterrorism Plan, evidence of a possible biological attack will be
reported to the Moore, Richmond, or Montgomery Public Health Care Agency, Emergency
Medical Services (EMS), local police department, and if verified, to the State of North
Carolina Department of Health Services, FBI Field Office, and CDC. In a major event
members of the press/media will be escorted to the designated area where a Public
Information Center will be established.
The circumstances for communicating with the community and the media will be defined for
any disaster event (of an internal or external nature) that impacts the community health and
safety within the hospital campus.
7. FHC plans for communicating with purveyors of essential supplies, services, and
equipment once emergency measures are initiated.
Once emergency measures are initiated, the hospital utilizes its vendors list for essential
supplies, services and equipment and notifies each vendor by telephone (or other means if the
telephone system is not operational) to be on standby to respond to the hospital’s needs should
they arise.
8. FHC plans to communicate with other healthcare organizations regarding essential
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elements of their command structures and control centers for emergency response;
FHC has communicated with other health care organizations essential elements of our
command structures and control center for emergency response as indicated in the EOP
above, in the IC/ACC section.
9. FHC plans to communicate with other healthcare organizations regarding names and
roles of individuals in their command structures and command center telephone
numbers;
FHC has communicated with other health care organizations the names and roles of
individuals in our command structures and control center for emergency response as indicated
in the EOP above, in the IC/ACC section.
10. FHC plans to communicate with other healthcare organizations regarding resources
and assets that potentially could be shared in an emergency response;
The logistics leader is responsible for assessing what resources and assets (such as personnel,
beds, transportation, linens, fuel, personal protective equipment, medical equipment and
supplies) can potentially be shared with other local health care organizations; or with nonlocal health care organizations in the event of a regional or prolonged disaster. The decision to
transfer resources and assets will be made by the incident commander or designee predicated
on FHC current and potential impact by a disaster or its escalating potential within the
community.
11. FHC plans to communicate with other healthcare organizations regarding names of
patients and deceased individuals brought to their hospitals in accordance with
applicable law and regulation, when requested;
In a disaster all patients brought to FHC are entered into a master patient triage roster that will
be located in the triage area and continually be submitted to the incident commander for
updates to other health care organizations in accordance with applicable law and regulation,
when requested. The roster will include patient’s names and deceased individuals brought to
FHC.
12. FHC defines the circumstances and plans for communicating information about
patients to third parties (such as other health care organizations, state health dept.
police, FBI, etc.);
The circumstances for communicating information about patients with community third
parties will be defined for any disaster event (of an internal or external nature) that impacts
the community health and safety within the hospital campus and as required by laws and
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regulations.
13. FHC plans to communicate with identified alternative care sites;
In the unlikely event the facility is deemed unsuitable for continued occupancy or cannot
support adequate patient care, communication will be coordinated through a collaborative
effort between the IC/ACC, Operations, Planning, and Logistics sections. The management
of necessary patient materials, the transfer of medications, medical records, medical
equipment, as well as transportation arrangements and tracking patients to and from the
alternative care site(s) is also a collaborative effort. Communications to county agencies and
other healthcare facilities to find potential adequate outside facilities may be obtained through
the SMART system, cell phones, or the UHF Communications (NCMCN).
14. FHC established back-up communication systems and technologies;
FHC alternative communication systems include runners, hand-held disaster radios, two-way
radios, cellular phones, amateur radios, email, etc. It is the responsibility of the IC/ACC to
ensure as many means of communication are utilized appropriately and when needed.
FHC ESTABLISHES STRATEGIES FOR MANAGING RESOURCES AND
ASSETS DURING EMERGENCIES (EM.02.02.03)
1. FHC has planned for obtaining supplies that will be required at the onset of an
emergency response (medical, pharmaceutical, and non medical supplies);
FHC maintains on hand supplies that may be required for an extended emergency at all times
(see appendix - assets and resource inventory list) for those supplies with short shelf life and
those that require continual replenishment, FHC will contact supplier immediately upon
suspecting the onset of an emergency and stock up for a minimum of 96 hours.
2. FHC has planned for replenishing medical supplies and equipment that will be required
throughout response and recovery, including personal protective equipment.
The plan consists of continually monitoring inventories required for an extended emergency
and the aftermath of an emergency during the recovery phase. FHC has memorandum of
understanding with suppliers to replenish medical supplies and equipment.
3. FHC has planned for replenishing pharmaceutical supplies that will be required
throughout response and recovery, including access to and distribution of caches
(stockpiled by the hospital or its affiliates, local, state, or federal resource) to which the
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hospital has access:
The plan consists of continually monitoring inventories required for an extended emergency
and the aftermath of an emergency during the recovery phase. FHC has memorandum of
understanding with Pharmaceutical suppliers to replenish pharmaceutical supplies and
equipment. FHC also has access to local, state and federal stockpiles.
4. FHC has planned for replenishing non-medical supplies that will be required throughout
response and recovery such as food, linen, water, fuel for generators and transportation
vehicles, etc.:
FHC maintains on hand supplies that may be required for an extended emergency at all times
(see appendix “C” assets and resource inventory list) for those supplies with short shelf life and
those that require continual replenishment, FHC will contact supplier immediately upon
suspecting the onset of an emergency and will strive to stock for a minimum of 96 hours.
The plan also consists of continually monitoring inventories required for an extended
emergency and the aftermath of an emergency during the recovery phase. FHC has
memorandum of understanding with suppliers to replenish non-medical supplies.
5. FHC has planned for managing staff support activities (such as housing, transportation,
stress debriefing, etc):
During an emergency, it may be necessary for the FHC to provide for various support activities
to ensure continuity over a period of time depending on the length of the response phase of an
emergency. Below are some of the activities the IC/ACC may plan for during an emergency:
Housing for Staff- If call in procedures for off-duty staff are activated, the IC/ACC will identify
areas where staff members can relax and sleep when not working.
6. FHC has planned for managing staff family support needs such as childcare, elder care,
communications, etc.:
Housing/Childcare for Staff Family Members- It may be necessary for staff members to
bring in family members or their children because they do not feel comfortable leaving them
during an emergency or because they have no one to care for them in their absence. It is
preferred that those staff members be the last resource during call-in procedures. If the
emergency creates a demand that would require these staff members to be necessary, the
IC/ACC will identify areas and personnel to assist in caring for these individuals. The Personnel
Pool Area will be contacted to determine availability of staff members to be assigned to staff
these areas.
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7. FHC has planned for potential sharing of resources and assets (such as personnel, beds,
transportation, linen, fuel, PPE, medical equipment and supplies, etc.) with other health
care organizations within the FHC community that could potentially be shared in an
emergency response:
FHC has processes for cooperative planning among organizations that together provide
services to the contiguous geographic area of the FHC service area to facilitate the timely
sharing of resources and assets. During community emergency planning meetings, resources
and assets that may be available from the member organizations is communicated.
8. FHC has planned for potential sharing of resources and assets with health care
organizations outside the immediate community of the FHC service area in the event of a
regional or prolonged disaster:
FHC has processes for cooperative planning among organizations that together provide
services to the contiguous geographic area outside of the immediate community to facilitate the
timely sharing of resources and assets. During community emergency planning meetings,
resources and assets that may be available from the member organizations is communicated.
9. FHC has planned for evacuating (both horizontally and when required by circumstances,
vertically) when the environment cannot support care, treatment, and services:
FHC has established an emergency procedure when evacuation of the hospital or unit is
required. In the unlikely event the hospital or a unit is deemed unsuitable for continued
occupancy or cannot support adequate patient care these procedures will be initiated. Staff is
educated on evacuating both horizontally and vertically. Staff is also trained to request
assistance in evacuating non-ambulatory patients.
The FHC Fire Response Plan (Code Red) dictates that in the event of a fire emergency, the
initial preferred evacuation method will be horizontal evacuation to an area of safe refuge / an
adjoining smoke compartment. If evacuation from the facility becomes necessary due to a
disaster situation where defending in place is not feasible and when the facility cannot continue
to support care, treatment and services, the incident commander and the fire dept. may initiate
vertical evacuation of the facility. If vertical evacuation becomes necessary, the following
protocol, as outlined in the Evacuation Plan, will be followed:
Vertical Evacuations
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1. If a vertical evacuation is required, the patients should be moved vertically down and
horizontally away from the affected area(s).
2. Elevators may be used for evacuation if authorized by the IC/ACC. The elevators used
must not service the affected area and must be controlled by trained personnel. Trained
personnel include Engineering staff, Security staff, or a member of the Fire
Department.
3. Once evacuation priorities have been established, the safest route to vertically evacuate
patients should be chosen and communicated by the IC/ACC. It may be necessary to
move patients vertically up and horizontally across then vertically down depending on
the location of the affected areas.
4. Holding areas for the patients shall be identified by the IC/ACC. These areas should be
chosen to keep all the patients from a specific unit together. Units can be mixed but
units should not be split between holding areas if at all possible.
5. Staff from evacuated units should stay with the patients from their respective floor/unit.
Once all patients have been evacuated to the holding area, the staff shall do a patient
count and check armbands against the census for their unit to ensure all patients have
been evacuated. Once the patient count and verification is complete, the IC/ACC shall
be advised that all patients have been evacuated.
E. Facility Evacuation
Once the notification is made, the IC/ACC shall begin planning for complete facility
evacuation. Evacuation of the facility shall be addressed in four parts:
1. Visitors

Because the facility does not have a way to track visitors coming and going from
the facility there is not a mechanism in place to account for all visitors. The
hospital operator should announce for all visitors to leave the facility
immediately. If a destination for the patients has been identified, the location may
also be paged overhead or otherwise communicated to the visitors.
2. Ambulatory Patients

Ambulatory patients and their medications, equipment, and pertinent
information, including essential clinical and medication-related information
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shall be moved as directed above to transportation as coordinated between the
IC/ACC and EMS.

Admitting staff shall track each patient as they leave the facility based on the
current computer census. Patient disposition shall be determined based on the
destination. If FHC will be staffing an alternate care site, the disposition will
be different than if being discharged home or to another facility. The
disposition determination shall be made by the IC/ACC.

The HICS 260- Patient Evacuation Tracking Form shall be utilized for patient
tracking. When more than two patients are being evacuated, the HICS 255Master Patient Evacuation Tracking Form shall be completed to gain a master
copy of all patients that were evacuated.
3. Non-Ambulatory Patients

Non-ambulatory patients and their medications, equipment, and pertinent
information, including essential clinical and medication-related information
shall be transported by ambulance or other vehicle designed for patient
transport as coordinated between the IC/ACC and EMS.

Admitting staff shall track each patient as they leave the facility based on the
current computer census. Patient disposition shall be determined based on the
destination. If FHC will be staffing an alternate care site, the disposition will
be different than if being discharged home or to another facility. The
disposition determination shall be made by the IC/ACC.

The HICS 260- Patient Evacuation Tracking Form shall be utilized for patient
tracking. When more than two patients are being evacuated, the HICS 255Master Patient Evacuation Tracking Form shall be completed to gain a master
copy of all patients that were evacuated.
4. Staff

FHC staff shall be evacuated based on facility needs. Staff members may be
needed to staff an alternate care site or to assist with the transfer of patients
from FHC to another facility.

All staff shall be tracked through the Personnel Pool Area using the
emergency list and other resources available through Human Resources. As
staff members are allowed to go home, the Personnel Pool Area can track
them through their clocking status on the Kronos system and or paper roster.
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10. FHC has planned for transporting patients, their medications and equipment, and staff
to an alternative care site or sites when the environment cannot support care,
treatment, and services:
Formal agreements and arrangements are in place so that patients may be transferred to a
facility that can provide adequate patient care. The Liaison Officer will be responsible for
inter-facility communication between the hospital and the designated alternative care site,
and for retaining records of which patients were transferred to and/or from an alternative care
site. The patient care unit transferring the patient is responsible for obtaining copies of the
patient’s medical records, gathering personal belongings and ensuring the patient’s
medications are continued throughout the transfer. If any hospital equipment is transferred
with the patient, the patient care unit is responsible for documenting what equipment was
transferred with the patient so that the equipment may be retrieved during the recovery phase
post emergency. The following arrangements and agreements are in place for transporting
patients to alternate care sites:




Ambulance contract agreements for transfer of patient between facilities.
Licensed vendors are contracted for providing van / bus transportation.
FHC owned vehicles are utilized.
FHC is provided with transportation vehicles arranged by the appropriate County
Emergency Medical Services (EMS).
11. FHC has planned for transporting pertinent information, including essential clinical
and medication related information, for patients to an alternative care site or sites
when the environment cannot support care, treatment and services:
When the environment cannot support care, treatment and services, and the IC/ACC has
ordered evacuation of the hospital to an alternate care site, it will be necessary to transfer
equipment, medications, essential clinical and medication-related information, and supplies
to the alternate care site. This shall be coordinated through the IC/ACC in conjunction with
Materials Management and Facility Services. See the section below regarding Alternate
Care Sites. The transfer of these components is made utilizing transportation agreements and
arrangements (indicated in 10 above) and all transferred equipment, and records are entered
into a transfer log for record keeping.
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FHC ESTABLISHES STRATEGIES FOR MANAGING SAFETY AND
SECURITY DURING EMERGENCIES (EM.02.02.05)
1. The hospital establishes internal security and safety operations that will be required once
emergency measures are initiated:
Safety and security measures and monitoring activities when emergency measures are
initiated play a vital role during response and recovery phases of emergencies. When
emergency measures are initiated, FHC mode of operations for safety and security shifts to
operating under emergency conditions and are covered in the appropriate policies and
procedures. The designated safety and security officers conduct staff education sessions and
monitor activities during emergency exercises and when emergency measures are initiated.
2. The hospital identifies the roles of community security agencies (law enforcement,
national guard, etc.) and defines how the hospital will coordinate security activities with
these agencies:
FHC has identified that the roles of community security agencies external to the hospital’s
buildings will be under the command of the highest-ranking law enforcement personnel on
site. Command of security inside the hospital’s buildings will be under the hospital’s Incident
Commander unless the incident commander deems that law enforcement intervention is
required inside the buildings, the police in conjunction with the Security Supervisor/designee
will assume command jointly.
3. The hospital identifies a process that will be required for managing hazardous materials
and waste once emergency measures are initiated:
It is recognized that once emergency measures are implemented, contracted hazardous waste
haulers may not be able to get to the hospital to haul hazardous materials and medical wastes
for days thus the hospital has set up a temporary secured storage area during emergencies.
The hospital’s normal spill response policy will continue to be followed in addition, storage of
hazardous materials and waste management will be temporarily placed in the designated
overflow areas until the emergency conditions have been lifted and vendors contracted for
hauling are able to get to the hospital and remove materials from the overflow areas.
4. The plan identifies means for radioactive, biological, and chemical isolation and
decontamination:
Facilities for decontamination are maintained and coordinated through the Facilities/
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Engineering Department, Security, Safety, Administration, Disaster and Safety Committees.
The effectiveness of this equipment and materials is periodically tested and evaluated.
FHC is equipped to manage decontamination with specified chemical agents, provided the
agent and concentration is known. FHC staff can utilize the primary decontamination shower
outside of the Emergency Department ambulance entrance and/or set up portable
decontamination showers if the incident warrants. Radiological emergencies are responded to
in concert with the Radiation Safety Officer. Biological emergencies are responded to in
concert with Infection Control or physician. Chemical decontamination situations are
responded to in concert with the Safety Officers.
The hospital has designated a decontamination area with a separate ventilation system or
ventilation shutoff available for radioactive or chemical isolation and decontamination.
Personnel are trained in the response to radiation or hazardous material contamination.
A separate Bioterrorism Preparedness Plan has been developed, reviewed, and approved by
hospital and is included in the hospital’s disaster manual.
Hazmat events including radioactive, chemical & biological events are handled based on FHC
IC/ACC & Operations Section Hazmat / Decontamination procedures for emergency
departments and support departments. The organization’s biological response plan will be
supplemented with the city and/or county Emergency Services & Hazmat team expertise.
Pursuant to exposure conditions, FHC may establish a chemical hazmat decontamination
triage setting external to Emergency Department when appropriate and in unknown exposures
defer to the local fire department Hazmat team who has authority to command all emergency
HAZMAT events.
Upon identification of a radiological hazmat events, FHC will establish an external hazmat
decon triage setting per the radiological plan. The facility Radiation Safety Officer will act as
Liaison and coordinate activities with external hazmat/ NRC entities.
Upon identification of a biological event as confirmed by the public health epidemiologist,
FHC will follow all aspects of the Bioterrorism Response Plan.
FHC has limited number of isolation rooms and is not equipped to deal with mass isolation
that may be required under emergency conditions. Once it is determined that isolation of an
area is required, security personnel, or designee, will be posted at all point of entry and exits
from the area to ensure that the area remains confined as directed by the incident commander.
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The department of facilities/ engineering will respond to isolate recirculation of ventilation
systems from the isolated area wherever possible or may initiate a fan shutdown in the area.
6. The hospital establishes processes for controlling entrance into and out of the health care
facility during emergencies:
At the time the Emergency Operations Plan is activated, the Security Department personnel
on duty will be responsible for securing all exits and entrances with the exception of the
ambulance entrance. Personnel of the hospital are required to wear nametags or carry cards
identifying them as personnel. Only persons with proper identification will be admitted to the
hospital during an emergency.
7. The hospital establishes processes for controlling the movement of individuals within the
health care facility during emergencies:
During emergency conditions, when it becomes necessary to control the movement of visitors
and staff horizontally and vertically in order to facilitate an effective environment during
emergencies; movement within the hospital will be controlled by security designee through
security check points, control of elevators, control of doors, control of staff that does not have
a need to perform essential functions, controls to ensure that necessary logistics receive
preference for reaching their intended destinations. Movement within the hospital during
emergencies will be controlled based on the following priorities:
 Priority 1; only those personnel that are properly identified, assets and logistics that are
necessary in response to the particular emergency at hand will be permitted.
 Priority 2; only those personnel that are properly identified, assets and logistics that are
necessary for the clinical needs of patients will be permitted.
 Priority 3: only those personnel that are properly identified, assets and logistics that are
needed for other than emergency purposes will be permitted.
8. The hospital establishes processes for controlling traffic accessing the health care facility
during emergencies:
Signs will be posted on the hospital campus directing overflow emergency vehicle in terms of
locations for decontamination facilities and parking for emergency vehicles.
Traffic flow on the campus will be controlled by security and law enforcement personnel only
allowing authorized vehicles to enter the campus during emergencies.
Efficient traffic flow is also established as follows:
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

Traffic control signs to show external and internal routing of casualties and other
traffic are used.
The IC/ACC will assign appropriate staff to perform traffic control and security
functions during emergencies.
FHC DEFINES AND MANAGES STAFF ROLES AND
RESPONSIBILITIES (EM.02.02.07)
1. Staff roles and responsibilities are defined in the EOP for all critical areas
(communications, resources and assets, safety and security, utilities, and clinical
activities):
See the Emergency Operations Plan (EOP) section (EM.02.02.01) for a complete description
of staff roles and responsibilities for all the six critical areas.
2. Staff is trained for their assigned roles during emergencies:
FHC discusses roles and responsibilities during Safety or Disaster Committee meetings and
provides training (through NIMS, and in-house training) for the specific roles assigned to staff
during emergencies. The staff roles and responsibilities are also assessed during exercises
conducted and opportunities for staff improvement in their roles are then implemented.
3. The hospital communicates to licensed independent practitioners their roles in
emergency response and to whom they report during an emergency:
FHC discusses roles and responsibilities of licensed independent practitioners (LIP) during
Disaster Committee meetings and provides training (through NIMS, and in-house training) for
the specific roles assigned to independent practitioners during emergencies. The roles and
responsibilities are also assessed during exercises conducted and opportunities for LIP
improvement in their roles are then implemented.
4. The hospital establishes a process for identifying care providers and other personnel
assigned to particular areas during emergencies:
FHC personnel are identified during emergencies by means of donning their staff
identification badges. If an employee does not have his/her badge or it cannot be located,
temporary badges can be obtained through the Human Resources Department, upon
verification.
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During a disaster “Code Triage”, FHC staff members are expected to return to their units and
provide support to the needs of their departments. Departments are to report their staff and
bed availability to the IC/ACC. Selected staff members are responsible for carrying out a
function on the HICS organizational chart. These staff are to report to the IC/ACC and then
to their pre-designated section meeting location to coordinate response activities. These staff
will wear their appropriate HICS Section or Unit Leader vest indicating their title to inform
others they are responsible for that function. In addition, supervisors are to send any extra
staff to the Personnel Pool to help the organization respond to the needs of the disaster.
The assignment of staff response activities during other emergency situations are described
within the specific disaster response policy and procedure (i.e. Code Pink, Code Yellow, etc.)
and included in department specific trainings.
FHC MAY GRANT DISASTER PRIVILEDGES TO VOLUNTEER
LICENSED INDEPENDANT PRACTITIONERS (EM.02.02.13)
The Personnel Pool will assign roles as requests for manpower are received. In the event
volunteers from the community come to the hospital, their credentials will be verified through
the Medical/Technical Specialist.
CREDENTIALING OF VOLUNTEERS
During disaster situations, members of the community may report to the facility wishing to
provide volunteer assistance. Some volunteers may have specific medical licenses and skills that
can be valuable to patient care. These could be physicians or other medical professionals. These
volunteers will be directed to the Personnel Pool and their names provided to the Human
Resources Department or in their absence, Nursing Staff Office to verify licensure. If licensure
can be verified, the volunteers will be used as necessary in conjunction with hospital staff. If
licensure cannot be verified, the volunteers can be used in roles that are not directly related to
patient care. See the Medical Staff Bylaws for more detail regarding Emergency Credentialing
of Physicians or the Human Resources policy for the procedure for assigning emergency
responsibilities to volunteer practitioners.
FHC ESTABLISHES STRATEGIES FOR MANAGING UTILITIES
DURING EMERGENCIES (EM.02.02.09)
1. The hospital identifies an alternative means of providing electricity in the event that
their supply is compromised or disrupted:
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Alternative means of meeting essential building utility needs such as power, medical gases,
water, ventilation, and fuel sources are coordinated in advance and tested through the
Facilities/ Engineering Department as part of the Utility Systems Management plan to ensure,
to the extent practicable, uninterrupted services. If necessary, external arrangements and
contracts for essential services are coordinated through the HICS Logistics Section.
FHC has a reliable, adequately sized and fueled emergency generation system consisting of
multiple generators capable of providing for effective operations under emergency conditions.
2. The hospital identifies an alternative means of providing water needed for consumption
and essential care activity in the event that their supply is compromised or disrupted:
Alternative means of meeting essential building utility needs such as power, medical gases,
water, ventilation, and fuel sources are coordinated in advance and tested through the
Facilities/ Engineering Department as part of the Utility Systems Management plan to ensure,
to the extent practicable, uninterrupted services. If necessary, external arrangements and
contracts for essential services are coordinated through the HICS Logistics Section.
Water needed for consumption and essential care activities have been calculated based on
need and is stored on premises at the hospital. During emergencies the hospital will
implement conservation measures.
3. The hospital identifies an alternative means of providing water needed for equipment
and sanitary purposes in the event that their supply is compromised or disrupted:
Alternative means of meeting essential building utility needs such as power, medical gases,
and water, ventilation, and fuel sources are coordinated in advance and tested through the
Engineering Department as part of the Utility Systems Management plan to ensure, to the
extent practicable, uninterrupted services. If necessary, external arrangements and contracts
for essential services are coordinated through the HICS Logistics Section.
Water needed for dialysis equipment, dish washing, instrument washing, hand washing and
for other equipment and sanitary purposes, has been calculated based on need to strive for an
extended period of 96 hours and is stored on premises at the hospital. During emergencies the
hospital will implement conservation measures.
4. The hospital identifies an alternative means of providing fuel required for building
operations or essential transport activities in the event that their supply is compromised
or disrupted:
Alternative means of meeting essential building utility needs such as power, medical gases,
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and water, ventilation, and fuel sources are coordinated in advance and tested through the
Facilities/ Engineering Department as part of the Utility Systems Management plan to ensure,
to the extent practicable, uninterrupted services. If necessary, external arrangements and
contracts for essential services are coordinated through the HICS Logistics Section.
Diesel fuel required for operation of the emergency generators and other fuels required for
operations of vehicles have been calculated and are stored on site at the hospital to support an
extended period of 96 hours.
5. The hospital identifies an alternative means of providing other essential utility needs
(ventilation, medical gas/vacuum systems, etc.) in the event that their supply is
compromised or disrupted:
Alternative means of meeting essential building utility needs such as power, medical gases,
and water, ventilation, and fuel sources are coordinated in advance and tested through the
Facilities/ Engineering Department as part of the Utility Systems Management plan to ensure,
to the extent practicable, uninterrupted services. If necessary, external arrangements and
contracts for essential services are coordinated through the HICS Logistics Section.
These essential utilities have been calculated based on needs for an extended period of 96
hours and are provided as follows:
 Ventilation; all critical care areas in the hospitals have their HVAC systems
connected to the emergency generators power source so that they will continue to
operate during commercial power interruptions.
 Other areas that may desire ventilation during emergencies; will be provided by spot
coolers on an as needed basis. The spot coolers will be connected to emergency
power receptacles. FHC maintains a supply of spot coolers at the hospital.
 Medical Gases; the medical air compressor and control circuits for other types of
piped medical gas systems are connected to emergency power. Provisions have been
made for portable air cylinders and appropriate regulators to enable stand-alone
operations where medical air may be required (ventilators, etc.). The oxygen manifold
is adequately sized with main and reserve cylinders and additional back up cylinders
to enable functioning for 96 hours. The medical vacuum system is connected to an
emergency power source and as a backup, all critical care units in the hospital are
provided with battery operated suction pumps located on crash carts and in the unit
storage rooms.
FHC ESTABLISHES STRATEGIES FOR MANAGING PATIENT
CLINICAL AND SUPPORT ACTIVITIES DURING EMERGENCIES
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(EM.02.02.11)
1. The hospital manages the clinical activities required as part of patient scheduling, triage,
assessment, treatment, admission, transfer, discharge, and evacuation during
emergencies:
Upon activation of the Emergency Operations Plan, normal admission requirements will be
abolished. Initially, admissions to the hospital will be limited to those whose survival
depends upon services obtainable only through hospital bed care.
Outpatient care will be restricted to those whose lives may ultimately depend upon the present
expenditure of medical supplies and health manpower time.
All elective admissions and procedures may be canceled or postponed, including elective
surgery, non-emergency outpatient procedures and transferring patients who are stable to be
discharged.
Patients may be transferred to other facilities so those emergency victims may be
accommodated.
Individuals may be redirected or relocated for a Medical Screening Exam in the event that the
hospital’s Emergency Operations plan is activated. (Section 1135(b) of the Social Security
Act §489.24(a)(2).
In the event that the hospital’s Emergency Operations Plan is activated, persons may be
transferred prior to being stabilized if, based upon the circumstances of the emergency the
hospital is unable to provide proper care, treatment or services. (Section 1135(b) of the Social
Security Act §489.24(a)(2).
2. The hospital manages clinical services for vulnerable populations served by the hospital,
including patients who are pediatric, geriatric, disabled, or have serious chronic
conditions or addictions during emergencies:
Clinical activities for vulnerable patient populations including pediatric, geriatric, disabled,
and psychiatric and addiction patients will be provided in the customary way but additional
emphasis will be placed on security, safety, mobility in terms of evacuation should it become
necessary during an emergency.
3. The hospital manages personal hygiene and sanitary needs of its patients during
emergencies:
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Personal hygiene and sanitary needs of patients during emergencies will be provided in terms
of assurance availability of water supply used for personal hygiene and domestic water pumps
at the hospital are connected to emergency power sources.
4. The hospital manages the mental health service needs of its patients during emergencies:
Personnel from Case Management (includes social workers, discharge planners) manage the
mental health service needs of patients and make referrals to the MRH Behavioral Assessment
Team or appropriate county mental health agencies, as needed.
5. The hospital manages mortuary services during emergencies:
The mortality rate during emergency conditions may increase due to casualties brought into
the hospital. The hospital is only equipped for handling a minimal number of mortality
casualties due to limited morgue refrigeration units. The hospital has an ample supply of body
bags to temporarily store casualties.
6. The hospital plans for documenting and tracking patients’ clinical information:
The hospital is equipped with back up data systems designed to be retrieved during emergencies
and be utilized for documenting and tracking patients’ clinical information. In addition, during
emergency conditions, paper forms will also be utilized to document and track patients’ clinical
information.
Incident Command/ Administrative Command Center (IC/ACC)
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FHC has established an “All-Hazards” incident command structure that is integrated into and
consistent with the community’s command structure. (See incident command structure appendix
for a complete diagram of the FHC incident command structure.)
Command and Reporting:
One of the persons noted below or their designee will assume the role of Incident Commander:
MRH: Administrative Nursing Supervisor
Security Supervisor
Safety Director
AD, Risk Management
VP, Quality
MMH: President
Administrator-on-Call
Executive Assistant
CNO/COO
RMH: President
Director, Risk/Safety
Nursing Supervisor
Administrator-on-Call
Safety Officer
EMS Director/designee
All section leaders (logistics, operations, planning, finance, safety officer) report directly to the
Incident Commander.
SETTING UP THE IC/ACC:
During the first fifteen minutes of a disaster, the hospital must investigate and organize its
resources to prepare for expected and unexpected problems. The Incident Command (IC/ACC) is
established for external or internal disasters or where deemed necessary by the Incident
Commander (IC). [Refer to Incident Commander Checklist Appendix]

IC/ACC LOCATION:
Moore Regional Hospital-Cancer Center classroom will be the designated IC/ACC
location. (Extension # 3333)
Richmond Memorial Hospital- Board Room will be the designated Incident Command
Center location. (Extension # 3633)
Montgomery Memorial Hospital- 2nd Floor nurses’ station will be the designated
Incident Command Center Location. (Extension # 5260 )

ALTERNATE IC/ACC LOCATION:
In the event the designated IC/ACC cannot be utilized or is not appropriate, an alternate
IC/ACC site will be announced and employees will be notified.
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
STAFFED BY:
Incident Commander
Public Information Officer
Liaison Officer (as needed)
Safety Officer
Section Chiefs (as assigned)
Situation Status Unit Leader (as needed)
Coordinating Assistants (as needed)
HAM Radio Operator – Moore Regional Hospital only

RESPONSIBILITIES OF THE INCIDENT COMMANDER:
1. Overall direction of hospital activities, including personnel assignment, supply and
equipment procurement.
2. Communication with Emergency Department (ED) or site affected (internal disaster)
regarding progression of the disaster.
3.
Ensure all sections (Logistics, Operations, Planning, Finance/Administration,
Medical/Technical, and Safety Officer) report in regularly and all essential functions
are assigned.
4.
Designates a “liaison” to communicate with public agencies (Law Enforcement,Fire
Department, Red Cross, Amateur Radio Emergency Services, and county emergency
management as available)
5.
Public Information:
a.
Designated staff will be assigned to the Patient Information Desk to assist
the public in the Family Waiting Area.
b.
Admitting will be responsible for collecting lists of patients, assuring all
patients are registered appropriately and tracking their location.
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
c.
PIO or designee will be present at the scene or available and responsible
for approving all public information released. Corporate Communications
will remain available as long as necessary to coordinate media/press
procedures.
d.
Volunteers and staff are not to release any information relating to the
disaster unless specifically instructed.
DESCRIPTION OF DUTIES
The first person in the Incident Command Post, or designee, other than the IC, will set up
the IC/ACC and temporarily act as secretary.
1. The Incident Commander coordinates the overall direction of hospital operations,
and if needed, authorizes evacuation. The IC also ensures communication with the
Press, Law Enforcement, Fire Department, Red Cross and other outside official
organizations as necessary. The IC designates a Public Information Officer (PIO) and
a Safety/Security Officer.
2. The Public Information Officer serves as the conduit for information to internal and
external stakeholders, including staff, visitors and families, and the news media, as
approved by the Incident Commander.
3. Liaison Officer functions as the incident contact person in the hospital Command
Center for representatives from other agencies.
4. The Safety/ Security Section Chief is responsible for ensuring the safety and security
of patients, visitors and staff, ensuring that when a facility lockdown is ordered by the
incident commander.
5. The Medical/Technical Specialist is responsible for organizing, prioritizing, and
assigning physicians to areas where medical care is being delivered. This section also
advises the Incident Commander on issues related to the Medical Staff.
6. The Operations Section Chief is responsible for all patient care activities including
discharging of patients, morgue functions and ancillary services. This section also
coordinates staff support functions.
7. The Planning Section Chief is responsible for projecting the resources needed for
possible long-term disaster response. This section also maintains the Labor,
Volunteer, and coordinates patient tracking/information activities. This section
coordinates resources with off-site facilities.
8. The Logistics Section Chief is responsible for the facility assessment and
maintenance and/or restoration of essential services, such as telephone, electricity,
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steam, and structural assessment. This section also responds to any hazardous
materials incidents and coordinates materials/supplies and nutritional needs.
9. The Finance/Administration Chief is responsible for maintaining documentation of
employee work hours and implements processes for payroll. It also completes and
maintains documentation to submit to OEMS/FEMA and insurance companies for
disaster financial claims.
The runner(s) provide communications between hospital departments if there is a loss of
internal telephone communications.
The HAM radio operators ARES (Amateur Radio Emergency System) provide vital
communications to the outside community and surrounding areas as needed and if
available.

4.
EQUIPMENT SUGGESTED AT INCIDENT COMMAND:
( ) Portable Radios (if needed)
( )
Cellular Phones
( )
Master Emergency Operations Plan
( )
Disaster Books for all sections
( )
Identification Vests
( )
Important Agencies Telephone Numbers
( )
Pens & Paper
( )
Amateur Radio Equipment
( )
Recording flip-chart
( )
Battery Powered Lights
( )
Batteries
( )
Signs for key areas
( )
Portable Radio Instruction Cards
( )
Hospital Floor Plans
Authority for Initiation Procedures in the Response and Recovery Phases of the
Disaster Plan:
The Code Triage – Disaster Plan identifies personnel who are authorized to activate (initiate)
the emergency response plan. This may include: Emergency Department Physician, Hospital
On Call-Administrator, Nursing Administrative Supervisor, Safety Officer, and Radiation
Safety Officer
The Incident Commander has the authority to clear the Code Triage (terminate) and
initiate the recovery phase of the Emergency Operations Plan.
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5. The EOP describes processes as to how the response and recovery phases are to be
activated: The disaster code (“Code Triage”) may be activated as described above and
entails notification by an initial overhead page by the hospital’s operator announcing code
triage.
Off duty staff is notified of a declared emergency by public announcements, telephone,
pages, verbal communication or a combination of these.
6. The EOP identifies the hospital’s capabilities and establishes response efforts when the
hospital cannot be supported by the local community for at least 96 hours;
Based upon the amounts and locations of current supplies, it has been determined by the
Disaster Committee that FHC will strive to self-sustain without the support of the community
for 96 hours before replenishing.
FHC maintains a documented inventory of assets and resources on-hand that is available on
site for use in an emergency. This inventory is monitored on an on-going basis, and full
inventory assessment and review is completed at least annually. Through this assessment the
FHC can identify its capabilities to be self-sustaining in the event that FHC cannot be
supported by our local community for 96 hours. Once the plan is activated, supplies and
equipment availability is closely monitored for depletion and replenishment. Supply
conservation activities may be required, and this will be done at the direction of the Logistics
Chief in collaboration with other members of the General and Command Staff. This
inventory includes but is not strictly limited to PPE’S, water, fuel, staffing, medical / surgical
supplies, pharmaceuticals and other back-up supplies as listed in appendix C.
7.
Establishment of an Alternate Care Site(s)
In the unlikely event the facility is deemed unsuitable for continued occupancy or cannot
support adequate patient care, communication will be coordinated through a collaborative
effort between the IC/ACC, Operations, Planning, and Logistics sections. The management
of necessary patient materials, the transfer of medications, medical records, medical
equipment, as well as transportation arrangements and tracking patients to and from the
alternative care site(s) is also a collaborative effort. Communications to the appropriate
County and other healthcare facilities to find potential adequate outside facilities may be
obtained through (SMART) system, cell phones, or the UHF Radio Communications
(NCMCS).
Alternate care sites are available through the FHC affiliation with other hospitals within the
state and region. If they are unable to accept patients from FHC during an emergency, the
Incident Commander will work with local emergency management agencies to determine
where patients can be relocated.
Determination of the site to be used in any given situation will be made at the time by the
incident commanders of the hospital. Consideration will be given to clinical services
required by the patients along with the nature of the emergency. Every effort will be made to
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provide the same quality of care at the alternate site chosen.
In the event of an overwhelming community disaster, FHC would operate under the process
for NDMS (National Disaster Management System).
The nurse assigned to each individual patient is responsible for packaging patient
medications and obtaining the patient chart to ensure that these items are sent to the
alternative site along with the patient. A list of inpatients to be evacuated will be generated
by the Administrative Nursing Supervisor/ Designee and provided to the Incident
Commander or designee, who will note the medications, equipment, and records sent with
the patient, along with the means of transportation and the designated evacuation site.
The individual assigned by the incident commander or designee will maintain patient
tracking to and from the alternate care site.
FHC REGULARLY TESTS ITS EMERGENCY MANAGEMENT PLAN
(EM.03.01.01)
1. The hospital tests its Emergency Operations Plan twice a year, either in response to an
actual emergency or in a planned exercise:
The hospital tests its EOP at least twice a year either in response to an actual emergency or a
planned exercise.
2. FHC conducts at least one exercise a year that includes an influx of actual or simulated
patients:
At least one of the exercises annually includes an influx of actual or simulated patients.
3. At least one exercise a year is escalated to evaluate how effectively FHC performs
when it cannot be supported by the local community:
At least one of the exercises annually is escalated where the scenario that is set, changes in
various stages to include greater severity, greater influx of patients and greater taxation on the
hospital’s resources and assets.
4. FHC participates in at least one community-wide exercise a year:
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At least one test or actual implementation per year involves participation with and by the local
the county/city and other public safety agencies, to improve communications and coordination
of activities.
5. Planned exercise scenarios are realistic and related to the priority emergencies identified
in the hospital’s Hazard Vulnerability Analysis.
Exercises are designed to test the EOP and preparations for specific events predicted as high
potential events by the HVA priorities and are as realistic as possible. The scenarios and
objectives are designed to test the plans, and to objectively measure performance in key issues
and activities against our expectations, and to focus improvements where the evidence
indicates that are needed. Performance is and will be monitored in terms of timeliness and
effectiveness of staff notification of events, internal and external communications, availability
and mobilization of resources, and effective and timely patient management. Where
opportunities for improvement are identified, they will be developed and tested.
6. During planned exercises, an individual whose sole responsibility is to monitor
performance and who is knowledgeable in the goals and expectations of the exercise
documents opportunities for improvement:
An individual who is not a participant in the exercise and whose sole responsibility is to
monitor performance during exercises is assigned to each exercise. This individual is
knowledgeable in the goals and expectations of the exercises and documents opportunities for
improvements objectively.
7. During planned exercises, the hospital monitors, at a Minimum; Communication,
including the effectiveness of communication both within the hospital as well as with
response entities outside of the hospital such as local governmental leadership, police,
fire, public health, and other health care organizations within the community:
The hospital utilizes a critique form to gauge the effectiveness of communications. The
metrics are based on a point scale to enable grading effectiveness. In addition, effectiveness is
also expressed in the exercise critiques and data is aggregated to seek opportunities for
improvements.
8. During
planned exercises, the hospital monitors, at a Minimum; Resource mobilization
and allocation including responders, equipment, supplies, personal protective equipment,
and transportation:
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The hospital utilizes a critique form to gauge the effectiveness of resource mobilization and
allocation including responders, equipment, supplies, PPE’S and transportation. The metrics
are based on a point scale to enable grading effectiveness. In addition, effectiveness is also
expressed in the exercise critiques and data is aggregated to seek opportunities for
improvements.
9. During planned exercises, the hospital monitors, at a Minimum; Safety and security:
The hospital utilizes a critique form to gauge the effectiveness of safety and security. The
metrics are based on a point scale to enable grading effectiveness. In addition, effectiveness is
also expressed in the exercise critiques and data is aggregated to seek opportunities for
improvements.
10. During planned exercises, the hospital monitors, at a Minimum; Staff roles and
responsibilities:
The hospital utilizes a critique form to gauge the effectiveness of staff roles and
responsibilities. The metrics are based on a point scale to enable grading effectiveness. In
addition, effectiveness is also expressed in the exercise critiques and data is aggregated to
seek opportunities for improvements.
11. During planned exercises, the hospital monitors, at a Minimum; Utility systems:
The hospital utilizes a critique form to gauge the effectiveness of utility systems. The metrics
are based on a point scale to enable grading effectiveness. In addition, effectiveness is also
expressed in the exercise critiques and data is aggregated to seek opportunities for
improvements.
12. During planned exercises, the hospital monitors, at a Minimum; Patient clinical and
support care activities:
The hospital utilizes a critique form to gauge the effectiveness of patient clinical and support
care activities. The metrics are based on a point scale to enable grading effectiveness. In
addition, effectiveness is also expressed in the exercise critiques and data is aggregated to
seek opportunities for improvements.
13. Exercises are critiqued to identify deficiencies and opportunities for improvement
based upon monitoring activities and observations during the exercise:
Each exercise is critiqued and identifies deficiencies and opportunities for improvement that
are based on monitoring activities, observations and metrics utilized to gauge strengths and
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weaknesses.
14. Completed exercises are critiqued through a multi-disciplinary process that includes
administration, clinical (including physicians), and support staff.
Critique data from the exercises, are also reviewed and critiqued again through the Disaster/
Safety Committee and Quality/ Clinical Performance Committee members including
representatives from administration, clinical services, physicians and support staff.
15. The hospital modifies its emergency operations plan in response to critiques of exercises
The strengths and weaknesses identified in exercise critiques are utilized to modify the
emergency operations plan.
16. Planned exercises evaluate the effectiveness of improvements that were made in
response to critiques of the previous exercise:
During exercises, an evaluation is conducted of the effectiveness of improvements that were
made in response to critiques from previous exercises.
17. The strengths and weaknesses identified during exercises are communicated to the
multidisciplinary improvement team responsible for monitoring environment of care
issues:
From aggregated data that precipitates from drill critiques and metrics utilized to gauge the
effectiveness of exercises, strengths and weaknesses that are identified during exercises are
communicated to the Disaster/ Safety and Quality/ Clinical Performance Committees.
ORIENTATION AND EDUCATION (HR.2.30):
Training documentation will be recorded in the individual’s employee file. Employees attend New
Employee Orientation, organized through Human Resources, at the time of hire where general
information and education regarding the emergency operations plan is provided. Continuing
education will be conducted at least annually during required annual reviews or educational
presentations. The training systems (and post test) provide required EC elements, including
utilities. Staffs are apprised of current, relevant disaster related action items through various internal
written correspondences, including but not limited to the FHC FirstNews, and other periodic
correspondences.
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5.0 PROGRAM PERFORMANCE IMPROVEMENT PROJECTS AND
INDICATORS
FHC has developed and implemented a systematic, organization-wide approach to developing
and maintaining performance improvement (PI) programs and projects that are meaningful,
realistic, adjustable and based upon relevant data and customer feedback. This PI model provides
a framework for the management of performance dimensions, as well as a standardized structure
for cause analysis, investigations, problem-solving and issue resolution. The key PI model
aspects include planning, designing, implementing, checking, and improving the performance
improvement program development and management. The standards and metrics by which
performance relative to this plan will be measured are predicated upon organizational
experiences, identified risks, inspection results, equipment trends, as well as Emergency
Management and/or FHC Safety Committee recommendations.
2009 Emergency Management Plan (Mid Year) Goals:
1.
Improve staff education in responding to an emergency, with a focus on disaster
equipment training (decontamination showers, personal protective equipment, surge
capacity tent, etc.). Develop and implement on-line learning modules for Incident
Command and disaster response.
2.
Establish alternate care site with procedures for activation.
3.
Organize and inventory all HRSA disaster supplies.
4.
Train Administration on Emergency Operations Plan activation and implementation.
5.
Continue County and Community collaboration for preparing and responding to a
disaster.
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