F323 – Safety and Supervision



Keeping Emergencies From Becoming Disasters Through PLANS, PREPARATION and TRAININGRay Miller, BS, MSOSH, GPDisclaimerHas 34+ years in HC safety/risk (29+ years in post-acute care)Serves on the AHCA Professional Development Work GroupServes on the AHCA Emergency and Disaster Prep CommitteeIs a former corporate safety director for several LTC companiesSpent his career developing risk & safety strategies, programs & solutionsIs a founding member of the Direct Supply-sponsored Loss Prevention ForumIs a board member for University of Wisconsin, Eau Claire, CHAASE (Center for Health Administration and Aging Services Excellence)22Copyright 2014-2015 Direct Supply, Inc. All rights reservedRay Miller MSOSH, GP Educator, Story-teller, WandererDirect Supply Dir. of Risk & Safety Solutions414 405 0492; rmiller@ 6767 N. Industrial Rd. Milwaukee WI 53223The materials, comments and other information contained in this presentation are intended to provide general informationbut not advice about certain regulations and initiatives.This information is not and not intended as legal or other advice, and each situation may vary depending on the particular facts and circumstances.You should not act upon this information without first consulting with qualified legal counsel.Thank you.3? 2014-15 Direct Supply, Inc., all rights reserved1109344-128639611 Mar 11 – 9.0 Tohoku Earthquake 45 mi. off Japan’s coastSeafloor slab = 50 miles x 180 milesWaves struck 30 minutes later7Highest waves = 124 feet2/27/2017Reached 6 miles inlandDirect Supply 2014 Webinar Series: July Broadcast6Describing EventsHazards and VulnerabilitiesSheltering-In-Place and EvacuationWritten PlansFederal and State Emergency ManagementICS (Incident Command System) and NIMS (Nat. Incident Command System)Checklists and TrainingAgendaKeeping Emergencies From Becoming Disasters ThroughPLANS, PREPARATION and TRAINING? 2014-15 Direct Supply, Inc., all rights reservedSIDEBAR: Anne Morrow Lindbergh“My life cannot implement in action the demands of all the people to whom my heart responds.”Neal A. Maxwell, Apr. 1974“That's good counsel for us all, not as an excuse to forgo duty, but as a sage point about … the need for quality in relationships.”11Michael Laughrun -- Consulate Management “Finding ways to relieve the anxiety of the situation for the Residents and Staff is something that we probably don’t address as much as we should.”? 2014-15 Direct Supply, Inc., all rights reservedOne DefinitionAn event causing significant disruption of care or treatment AND / OR harm to people, facility, grounds or utilities.A Definition and the Nature of Emergency EventsUnplanned … many forms:Hurricane (Impending)Elopement (Vigilance)Fire Within (Immediate)Responses differ based on:TIME: Immediate vs. ImpendingSCOPE: Facility vs. Local vs. “Wide” AreaEVACUATION: Internal / Local / Remote vs. Shelter-in-placeFlorida Health Care Education and Development Foundation, 2008, National Criteria for Evacuation Decision-Making in Nursing Homes, developed through aproject funded by the John A. Hartford Foundation.12? 2014-15 Direct Supply, Inc., all rights reservedDirect Supply 2014 Webinar Series: July Broadcast13Describing EventsHazards and VulnerabilitiesSheltering-In-Place and EvacuationWritten PlansFederal and State Emergency ManagementICS (Incident Command System) and NIMS (Nat. Incident Command System)Checklists and TrainingAgendaKeeping Emergencies From Becoming Disasters ThroughPLANS, PREPARATION and TRAININGWhich Hazards Have You Planned For?Natural HazardsFiresFloodsWildfiresTsunamisVolcanoesSink holesTornadoesHurricanes(Alert, Watch, Warning, Post-Disaster)EarthquakesExtreme ColdExtreme HeatWinter StormsPandemic eventsLandslides & Debris FlowThunderstorms & Lightning? 2014-15 Direct Supply, Inc., all rights reservedTerrorismExplosionsNuclear BlastsArmed Intruder / Active ShooterChemical ThreatsBiological ThreatsHostage SituationBarricaded SuspectRadiological Dispersion DeviceTechnological HazardsExtended power outagesGas Rupture/ExplosionNuclear Power PlantsHaz. Mat IncidentsRailway spur/lineChemical Plants14FreewaysLeveesITSIDEBAR: Creating Our Own Hazards -- Compartmentalization TRUE or FALSE?Smoke causes most fire deathsSmoke compartments save lives“… painted the caulking red …”Compartments are sometimes violated15? 2014-15 Direct Supply, Inc., all rights reservedResident Vulnerabilities -- Planned For?*AMICHFFallsPainToiletingNutritionDiabetesDementiaHydrationBehaviorsElopementRespiratoryPneumoniaShelter in Place (SIP) andEvacuation?DepressionMedicationsHypertensionInfection ControlHospice/End-of-lifeWound management16? 2014-15 Direct Supply, Inc., all rights reservedAgendaKeeping Emergencies From Becoming Disasters ThroughPLANS, PREPARATION and TRAININGDescribing EventsHazards and VulnerabilitiesSheltering-In-Place and EvacuationWritten PlansFederal and State Emergency ManagementICS (Incident Command System) and NIMS (Nat. Incident Command System)Checklists and Training18What Happens Here?Notification / ActivationMitigationEvent RecognitionPreparationNormalizationIncident OperationsImplementationShelter-In-PlacePreparationRecovery & LearningTransition to Recovery19? 2014-15 Direct Supply, Inc., all rights reservedShelter With-in TheoryLife Safety Code, NFPA 101“The residents of a health care facility can remain safe even when close to a fire IF:Corridor walls have been constructed (and maintained) properlyAppropriate smoke and fire barriers have been installed Approved fire detection and suppression systems havebeen installed and maintained.”“… violating fire doors…”Hazardous areas are protected What else do you prepare for?20? 2014-15 Direct Supply, Inc., all rights reservedSheltering-In-Place FundamentalsGeneratorSupport critical for care functions(O2, trachs, interal feeding/hydration)Fuel/re-fueling, testing, circuitsMaintain lights, temps …Vendor supportFailure/backupSecurityCommunicationsRounds, reporting, alertingIDs/photo for staff / volunteersVisitors’ reception area / sign inNFPA: Coordinate with local law enforcementWater and Power188061671487Pre-event relationshipsEducate “them” on acuitiesContact names and numbers availableCommunicate: utilities/employees/families Educate “them” on power grid restorationBasic SuppliesName/title of Responsible Party for:a. Power b. Staffingc. Food/waterd. Communicationse. Linen, disposablesf. Sanitation/cleaningMaintain inventory lists21What Happens Here?Transition to RecoveryReturn / MobilizationImplementation/ MobilizationNotification / ActivationMitigationEvent RecognitionPreparationIncident OperationsEvacuation24PreparationRecovery & Learning? 2014-15 Direct Supply, Inc., all rights reserved26SIDEBAR: Evacuation “Opportunities”Common evacuation problems:Long travel timesContracts not honoredUnprepared/unavailable host facilityInsufficient staffing, food, water, suppliesComplicated Resident medical needsLost ED plansRe-enteryDepartment of Health and Human Services, Office of Inspector General, 200627Transportation-related Evacuation ChallengesReasons other than “lack” of ground transportation:Incorrect assumptions(drivers, fuel, vehicles destroyed, size, tyRpeE, “AloLaIdS-aTbIiClityP”,laronadRceonvdiietiwonss)Poor planningand Solid Table Tops(receiving facility, en-route medical needs, GPS vs. maps, distance vs. time) 4 Rules of Thumb:Plan for pre- and post-event evacuations / transportsLoading + Travel < Total Available TimeIdentify three transportation providersIt’ll NEVER happen the way you practicedWe practice to learn how to decideCitation: Florida Health CareEducationand DevelopmentFoundation,2008, National CriteriaforEvacuation Decision-Makingin Nursing Homes,developedthroughaprojectfundedbythe John A. HartfordFoundation.Forfurtherinformation,pleasevisit. SIDEBAR: Evacuating NH Residents to Nonclinical Buildings“A primary finding was that evacuating nursing home residents tobuildings that are not designed to support nursing activities (e.g., school gymnasium or church) adversely affected resident feeding, sleeping, movement, and security.Non-clinical buildings also presented serious occupational health concerns for nursing staff members providing care emergencies.”Three overarching themes:RESIDENT: medical or resident rightsSTAFF: staff family, staff safety, or staff decision makingSTRUCTURAL: damage to the building or hosting-facility problems2/27/2017Haven of Last Resort: personal note, from a FriendFleeing Hurricane Rita, September 23, 2005: Bus fire near Wilmer, TX; 23 NH Residents died I&cid=1203832? 2014-15 Direct Supply, Inc., all rights reservedEvacuation Decision-making:Flexible, ResponsiveFlorida Health Care Education and Development Foundation, 2008, National Criteria for Evacuation Decision-Making in Nursing Homes, developedthrough a project funded by the John A. Hartford Foundation.? 2014-15 Direct Supply, Inc., all rights reserved34Evacuation v. Shelter-In-Place Decision MakingSIDEBAR: Bariatric Evacuations“Are you really prepared?” (1 of 2) (Email from a Friend) Hello:This should be a loud voice for lessons learned! This scenario is a post mortem of an actual event surrounding an obese resident. I had experienced and expressed frustration while attempting to realistically create an evacuation plan.We had obtained a 10 person sling. I now laugh at myself about my unrealistic equation of approximately 78 pounds of push / pull force per employee actually being a possibility. Keep in mind that this resident was housed on the second floor of our center.SIDEBAR: Bariatric Evacuations“Are you really prepared?” (2 of 2)Today around 10am this resident experienced sob with an O2 sat in the 70’s. Bipap was applied without good result. Poor response to stimuli, only to deep sternal rub911 was called noting that this was for a 780lbs. resident. Eighteen responders came to the call – police, ambulance, EMT, fire dept. But the arrival of the bariatric transport unit was delayed.It then took 75 min. to complete the transfer into the ambulance and it required sixteen men to push the stretcher up the portable ramp and into the ambulance.The responders followed to the hospital to unload ...SIDEBAR: Bariatric Evacuations A Few Items to ConsiderPlanning & Assessments: Pre-Admission ... Ongoing ... Post-event ... Care plan (Staff, equipment, sling, technique)Ground floor … close to exits Equipment, staff, protocols, trainingEvacuation routes … identified & tested … no obstaclesTriage: a] nature of the emergency, b] each resident c] staff and equipment resources37Ambulatory Non-ambulatory Bed Ridden Bed transport ... Be careful …? 2014-15 Direct Supply, Inc., all rights reservedSidebar: Bariatric Evacuations* Reality Check: Ashford and St. Peter’s Hospital, NHS(National Health Services, United kingdom)EXCLUSIONS:In a life-threatening situation when there is no time to carry out a planned move, the individual (staff) must assess each individual situation and, using their professional knowledge and judgment, act in the most appropriate way in order to reduce the risk to the lowest level.In the event of evacuation because of fire, patients39should be moved as quickly as possible by whatever means are appropriate...? 2014-15 Direct Supply, Inc., all rights reservedDirect Supply 2014 Webinar Series: July Broadcast40Describing EventsHazards and VulnerabilitiesSheltering-In-Place and EvacuationWritten PlansFederal and State Emergency ManagementICS (Incident Command System) and NIMS (Nat. Incident Command System)Checklists and TrainingAgendaKeeping Emergencies From Becoming Disasters ThroughPLANS, PREPARATION and TRAINING 628383117298323177501172983Emergency and Disaster Plans What Are the Objectives of Your ED Plan?1st:Protect and save lives2nd:Protect and minimize damage to propertyHOW?PREPARATION41? 2014-15 Direct Supply, Inc., all rights reservedRequirements for Emergency PlansFederal Regulations:F455 (Emergency power)F466 (Water supply)F517/K48 (Detailed written plans and procedures …missing resident)F518/K50 (Training and drills … unexpected times … varying conditions … 1/shift/quarter ... Responsibility … (competent…qualified…leader. … between 9:00 PM and 6:00 AM (coded announcement)Fed osha1904.39 Reporting fatalities and multiple hospitalizations to osha(a) Within 8 hrs. of death … or hospitalization of 3+ … oral report … telephone/in person to nearest area osha office OR 1-800-321-osha431910.38 Employee emergency plans.(c)(4) Procedures to account for all employees after evacuation? 2014-15 Direct Supply, Inc., all rights reservedGAO-06-443R Evacuation of Hospitals and Nursing Homes; Disaster Preparedness: Preliminary Observations on the Evacuation of Hospitals and Nursing Homes Due to HurricanesSIDEBAR: What ELSE do you have in your plans?Procedures (Meds, Linens/supplies, Dietary, Residents’ personals, Staff and Family, Charts …)Floor plan with sheltering in locations markedMutual aid agreements with other facilities“Approved” Fire Safety PlanTransportation contractsOrganizational charts46Evacuation maps? 2014-15 Direct Supply, Inc., all rights reserved852195928116FINAL RULE: 16 Sept 2016Effective: 15 Nov 2016Incorporation: 15 Nov 2016 “certain publications listed in the rule”Implementation: 15 Nov 2017Interpretive Guidelines expected “early 2017”*“The Federal government does not regulate assisted living facilities. Assisted living is a service recognized under several States’ Medicaid home and community-based services (HCBS) waivers.“State governments have jurisdiction in regulating these facilities and will continue to oversee the compliance of assisted living facilities with State law.”Members ImpactedThese include SNF, NF and ICF/IID. This final rule is not applicable to Assisted Living Providers. Certification/SurveyCertEmergPrep/HealthCareProviderGuidance.html Certification/SurveyCertEmergPrep/Downloads/SandC_EPChecklist_Persons_LTCFacilities_Ombudsmen.pdf -- Page 1 of 651 Patient Safety During EmergenciesApplies to 17 Medicare & Medicaid Providers & SuppliersEmergency Preparedness Final Rule600,000+ wordsEmergency Preparedness Regulations Applies ToHospices (§ 418.113)Long Term Care (LTC) Facilities (§ 483.73)Intermediate Care Facilities for Individuals With Intellectual Disabilities (ICFs/IID) (§ 483.475)Home Health Agencies (HHAs) (§ 484.22)2/27/2017Consistent Provisions Across All Providers & Suppliers“All Hazards”Based On AssessmentSubsistence needs, Evac & SIP, Tracking –R&SAnnual Review & UpdateEmergency/Standby PowerNFPA: Locate, install, test, inspect, maintainMaintain sufficient fuelAddress Fed and State RequirementsCoordinated (campus, community, HD, EMS …)Orientation, Annual, DrillsDemonstrate knowledge E. Emergency Preparedness LTC FacilitiesSubsistence (§ 483.73(b)(1))LTC facilities are required to provide subsistence needs for staff and residents, …evacuate or shelter in place, including,but not limited to:Food, water, and medical suppliesAlternate sources of energy/electrical powerEmergency and Standby Power Systems Do not Apply to ICF/IIDSafe and sanitary storage of such provisions 2/27/201756DOCUMENTED:Facility/community “all hazards risk assessment” (+ Missing Residents)Annual reviews and ongoing updatesINCLUDED:Strategies:identified risks b) needs of actual resident populationProvisions:continuity of operations b) succession plans c) delegation of authorityCoalitions:*local hospitals b) state/local officials c) state/local planning effortsParticipation:of RN and administrator b) in planning and developmentEmergency Plan Basics 57Why be involved in local ASPR/Hospital Coalitions:You develop relationships pre-eventThey provide assistance and trainingThey* receive federal funds(* Hospitals, Local Government, Emergency Personnel and other medical community)ASPR TRACIE: AgendaKeeping Emergencies From Becoming Disasters ThroughPLANS, PREPARATION and TRAININGDescribing EventsHazards and VulnerabilitiesSheltering-In-Place and EvacuationWritten PlansFederal and State Emergency ManagementICS (Incident Command System) and NIMS (Nat. Incident Command System)Checklists and Training59ICS (Incident Command System)*Internet-available FEMA Training & Management Principles/Practices for HC SystemsIS-100: Intro to ICS for HealthcareIS-120a: An Introduction to ExercisesIS-130: Exercise Evaluation and DesignIS-197: Special Needs Planning ConsiderationsIS-200: Applying ICS to Healthcare OrganizationsIS-247a: IPAWS Alerting Authority Online TrainingIS-700: Intro to NIMS61IS-800: Intro to National Response FrameworkIS-907: Active Shooter: What You Can Do? 2014-15 Direct Supply, Inc., all rights reservedICS (Incident Command System) Intro to National Incident Management System (NIMS)Course Map:Lesson 1: Understanding NIMS Lesson 2: NIMS PreparednessLesson 3: NIMS Communications and Information Mngmnt. Lesson 4: NIMS Resource Mngmnt.62Lesson 5: NIMS Command and Mngmnt.Lesson 6: Additional NIMS Elements and Resources? 2014-15 Direct Supply, Inc., all rights reservedDirect Supply 2014 Webinar Series: July Broadcast63Describing EventsHazards and VulnerabilitiesSheltering-In-Place and EvacuationWritten PlansFederal and State Emergency ManagementICS (Incident Command System) and NIMS (Nat. Incident Command System)Checklists and TrainingAgendaKeeping Emergencies From Becoming Disasters ThroughPLANS, PREPARATION and TRAINING CycleThe NIMS defines preparedness as:"a continuous cycle of planning, organizing, training, equipping, exercising, evaluating and taking corrective action in an effort to ensure effective coordination during incident response.” Supply 2014 Webinar Series: July Broadcast66Describing EventsHazards and VulnerabilitiesSheltering-In-Place and EvacuationWritten PlansFederal and State Emergency ManagementICS (Incident Command System) and NIMS (Nat. Incident Command System)Checklists and TrainingAgendaKeeping Emergencies From Becoming Disasters ThroughPLANS, PREPARATION and TRAINING rPAhWP0YMKHU6XC4EQFggcMAA&url=http%3A%2F%2Fhealth.state.mn.us%2Foep%2Fhealthcare%2Fsurge%2Fltcprepare.doc&usg=AFQjCNHl-d6qdu9oYrq3rWhOeSOmZdnJCg615192147616The National Incident Management System1060943114379 Emergencies From Becoming Disasters ThroughPLANS, PREPARATION and TRAININGDescribing EventsHazards and VulnerabilitiesSheltering-In-Place and EvacuationWritten PlansFederal and State Emergency ManagementICS (Incident Command System) and NIMS (Nat. Incident Command System)Checklists and Training68Direct Supply 2014 Webinar Series: July Broadcast“Guessing does NOT get you the ‘win’.It’s how you (respond).”Agent Gibbs Minutes From Engine Failure To Flawless Landing In The Hudson River: Lessons LearnedChesley Burnett "Sully" Sullenberger AA transport pilot, safety expert, and accident investigator from Danville, CA.He successfully ditched USA Flight 1549 in the Hudson River off Manhattan, New York City, on January 15, 2009, saving the lives of all 155 people on the aircraft.70? 2014-15 Direct Supply, Inc., all rights reserved Three Minutes From Engine Failure To Flawless Landing In The Hudson River: Lessons LearnedCHECKLISTS: Use them to improve Q of care and safety.REPEATED TRAINING:Common and rare eventsNOTE: Sully had never experienced an engine failure except in a simulator.LEADERSHIP:Effective team leaders assign roles, manage information, equipment and people. NOTE: A recent review found that 43 percent of errors were due to problems with team coordination.CULTURE OF SAFETY:You get better staff buy-in.They are more comfortable in monitoring and mentoring team members.? 2014-15 Direct Supply, Inc., all rights reserved72 and DrillsTraining is the foundation of preparedness and response.Mel Tobias – Sprenger Health Care“Each person HAS to know their duties ... When ‘it’ happens, it’s too late to look at a book.”What do you want them to be “good” at?Elopement prevention and response Falls prevention and responseFire, severe weather73Evacuations? 2014-15 Direct Supply, Inc., all rights reservedIn-Place and EvacuationnsDirect Supply 2014 Webinar Series: July Broadcast74Describing EventsHazards and VulnerabilitiesSheltering-Written PlaFederal and State Emergency ManagementICS (Incident Command System) and NIMS (Nat. Incident Command System)Checklists and TrainingAgendaKeeping Emergencies From Becoming Disasters ThroughPLANS, PREPARATION and TRAININGQUESTIONS? ................
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