Ifasc.org



Ambulatory Surgery CenterEmergency Preparedness ProgramAdministrative Instruction ManualPublished June 2017This manual is to assist the ambulatory surgery centers (ASC) to better understand the rationale for the emergency preparedness program and how to work through customizing it to your specific center. IntroductionPreviously, the ASCs were required to have emergency plans and procedures to meet the standards imposed by the Accreditation Association for Ambulatory Health Care (AAAHC) and the Indiana State Department of Health (ISDH) licensing rules and regulations. If the ASC was also accredited by either the Joint Commission (TJC) or Healthcare Facilities Accreditation Program (HFAP), plans and policies also were needed to meet those standards. Effective November 17, 2017, the ASCs must also meet the Conditions for Coverage (CfC) as published by the Centers for Medicare and Medicaid Services (CMS) related to Emergency Preparedness (45 CFR 416.54). In addition, the ISDH Public Health Preparedness and Emergency Response (PHPER) program through the Assistant Secretary of Preparedness and Response (ASPR) is promoting all healthcare organizations to coordinate and collaborate within a Healthcare Coalition (HCC) to develop interagency plans for dealing with a major disaster. The Indiana Federation of Ambulatory Surgical Centers (IFASC) has been authorized by the ISDH PHPER program to use ASPR funds to hire Vantage Point Consulting to develop templates to assist the ASCs to meet these requirements. These documents will most likely be asked for during any survey for review. However, it is more important that administration and staff have been trained and are knowledgeable regarding the plans and procedures and practice them during drills and/or exercises. General InformationYou will find all of the documents to have color coding on them. Each area with a color code requires action on the individual ASC in order to customize the document to your specific center. Yellow color coding: Generally, you need to select a word from the options given, and/or modify a list to reflect your center’s specific titles, process, documents, etc. Once you have determined the appropriate wording, make sure to delete the unnecessary words and remove the yellow highlights.Pink color coding – As there are so many variances in size and scope of the ASCs it is impossible to adequately develop one template that meets everyone’s needs. Therefore, the pink highlighted sections are further instruction regarding information you will need to develop and add to the document. Once you have determined the specific wording to add, make sure to delete the highlighted pink instructions.Blue color coding – These are references to appendices or other policies and procedures that give further detail regarding the topic. You can leave the blue color coding in place so that it is more easily visible when looking through the documents during an emergency, or remove the color coding and just leave the reference.These templates are for your consideration and do not have to be used as written. You have the option of using parts of them and incorporating that information into your existing documents or supplementing your existing plans/procedures with this information. You can use these documents as your base and add additional information from your existing plans/policies if that information is not currently in the templates. This is to be YOUR plans and policies and they must reflect your practices. Remember no regulatory organizations dictate the format for how you “write” your plans, policies and procedures, only that you have specific plans and policies and procedures, and that you follow/practice the plans and policies and procedures as written.For all of the documents, you can alter (or copy and paste) the general information into your center’s standard format for plans and policies and procedures. CMS requires the center to have a plan or policy and procedure for each of the documents we are including in this template version. This however is NOT all of the documents you will need to have and you should include in your final program additional documents related to risks identified by your center and/or policies required by other regulations. This may include but not be limited to the following policies:Bomb ThreatSevere Weather (Tornado/High Winds)Severe Weather (Ice/Snow/Blizzard)EarthquakeSecurity Alerts: Workplace Violence – Hostage – Active ShooterMissing PersonExternal Disaster (Mass Causality Incident/Medical Surge)Fire PlanChemical SpillInfluenza/PandemicInfectious DiseaseInternal Flooding/ Water DamageIsolation/Decontamination/Hazardous MaterialsDisaster Credentialing Waste Management ProgramAll programs, plans, and policies and procedures show an effective date as well as a review/revision process on an annual basis. This should be noted on each document following your standard procedure as well as being reported in your safety/emergency preparedness committee minutes.When you save the documents for your electronic record, you can use the name given or rename them according to your standard process. It is also suggested to add following the name, the effective date and subsequent review/revision dates, so when looking for an electronic document, it is easy to see the most current document, e.g., Emergency Preparedness Program_E7.12.17_R7.8.18 (E for effective and R for review/revision). If a document is revised, it is a good idea to record in your minutes what exactly was changed. Some organizations even highlight the changes on the documents, so it is easy to see what is different from previous version, and then the next time it is revised, to remove those highlights and make new highlights for new changes.Emergency Preparedness ProgramThis is the overall program guidelines for your emergency Preparedness program, explaining the components included. It includes the following sections and edits/actions you need to take:Title PageProvide your centers specific name. You may also want to include your address.Add the effective date (date approved by your standard processIntroductory ParagraphDescribe your Surgery Center, your accreditation status, your staff, and the services you provide. If you have multiple locations or are affiliated with a healthcare network system, provide that information.Emergency Preparedness ProgramNo action necessaryCooperation and collaborationPen and attach a document noting your communication with (or attempt to communicate with) partners in your community and healthcare coalition. (see Appendix 1 for sample documentation)Emergency /Disaster Definitions No action necessaryAll-Hazard ApproachNo action necessaryEmergency Operations Plan (EOP)Name the committee(s) responsible for approving your EOPDescribe the process for approval – including governing boardRisk AssessmentReferences Appendix 2 where you would attach your completed HVAWhen you conduct an HVA it is necessary to define and record in your minutes the number of highest risks you would definitely write a policy and procedure for. For example you may have identified 30 risks, but elect to make sure you have policies and procedures for the top 5 highest ranked risks. This does not mean that you cannot have more policies and procedures than this, but that you MUST have a policy and procedure for those 5. Describe how you collaborate within your community/district to complete the HVA. Documentation of the collaboration is imperative.MitigationNo action necessaryPreparednessNo action necessaryResponseNo action necessaryRecoveryNo action necessaryTraining and Testing ProgramIndicate the title of who is accountable for making sure staff are trained (this is not necessarily the person doing the training)e. and f. Appendix 3 includes 10 different exercises and observation/critique tools that were developed specifically for the ASCsAppendix 4 includes a template for an After Action Report AARIntegrated Health Systems – Applies only if you are part of a Healthcare system that include multiple facilities that are each separately Medicare certified. If that is the case, you can elect to have unified and integrated emergency preparedness program and should state that here. If elected you must Demonstrate that your facility actively participated in the development of the unified and integrated emergency preparedness program.Make sure that the program is developed and maintained to account for your facility’s unique circumstances, patient populations, and services offered.Demonstrate that your facility is capable of implementing an effective emergency operations plan and response.Include an EOP that meets the CMS requirements, including a risk assessment, a communication plan, and specific policies and procedures. You must also actively participate in drills/exercises.Acronyms and Definitionsif you add additional acronyms to this document or any other documents, please include them in this listingAppendicesThis is a list of Appendices provided. You can renumber them throughout the document, but make sure you change the number here and on the actual appendix. You can delete or add appendices as you deem appropriate. If you do not use electronic medical records, you can remove #14. ReferencesThis includes agency websites, relevant documents, websites for standards/regulations, and other website resources. You can add to this list as you deem appropriate.Emergency Operations Plan (EOP)This is an all-hazards plan that includes information/tasks that are relevant for any type or complexity of an emergency. It includes the following sections and edits/actions you must take to customize to your center.Title PageProvide your centers specific name. you may also want to include your address.Add the effective date (date approved by your standard processIntroductionList title of person/committee that developed the EOPDescribe process for development of EOP (similar to description for Emergency Preparedness ProgramAppendix 2 – substitute your completed HVAASC InformationComplete areas for organization name, address, county, district, phone/fax numbers, services provided/scope of practice, emergency contact informationIn primary service area, indicate essential functions that should continue to function if possible during an emergency, e.g., OR, Pre-op, Post-op. Areas that may be discontinues might include back office functions, testing procedures, consultations/evaluations for future procedures, etc.Appendix 6 includes a map of the 10 healthcare coalition districts, select which one you are located in. Appendix 8 references your center’s organizational chart and should be included thereAuthorityName the title of the person who has authority to activate the EOPHealthcare CoalitionNo changes neededFacility OwnershipIf you own your building, then state that here. If you lease space, describe your collaboration efforts with building management in regards to emergency preparedenss. Do they have a person that sits on your safety/emergency committee or do you sit on theirs?Hazard Mitigationi. Communications – modify list to include the redundant modes of communication you have access toii. Call back process – Appendix 5 insert your employee roster/contact information hereManagement of an incident – Appendix 10 for HICS information and Appendix 6 should be your external contact list with contact information.Resource Management – name your process for who oversees resource allocations.Infection Control/Hazardous Materials and Waste – reference your current policies for this and then if keeping blue highlights for visual ease, change text to blue highlights.Staffing – no changes necessaryPreparednessPolicies and Procedures – Edit list to include all polices and procedures related to emergency management processes. Add any additional policies and procedures not listed already.Plain Language –the recommendation is to use plain language for all emergency alerts, however if you are still using color/number/alpha codes, change langue here to reflect that. A guide to using plain language is included in the Resource Files. Evacuation – See evacuation policyIf you have agreement with adjacent medical facility, name that location hereIdentify back up sitesSee Appendix 15 for Alternate Site Agreement (insert any you have here) A sample agreement is included in these documents for your consideration if you don’t already have one completed.Resource and Asset Management – Appendix 11 – insert your current resource inventory list.Utilities Management (See Utility System Failure policy)Name person/company that manages your generatorDescribe the name/brand of your generatorIndicate how many hours of fuel you haveResponseIncident NotificationTitle of who receives notification Add name of network health system you are affiliated with or delete this munication Plan referenced as well as Appendix 6 for contacts.Initiating the EOPTitle of who is authorized to activateEdit to include plain language or reference your current code alert systemIncident Management Indicate title of who would do damage assessmentEdit list for options on how your center may be used during a community based disaster, this should be discussed with your local hospital, health department, and emergency management agency as well as your district healthcare coalition.Staff ResponsibilitiesIndicate how you identify staffReferences Emergency Tracking SystemAppendix 5 – include your staff roster/call back listAppendix 12 – includes information you can give to your staffName location where staff are to assemble for assignment if not needed in their primary area.Appendix 13 has list of supplies to keep in disaster toolbox/tote and Appendix 14 for your paper chart (if using electronic records – if not delete this reference here)References Volunteer Management PolicyPatient Care and Support ActivitiesIf you are not able to be in the building describe your process for how you can get information regarding scheduled patients to alert them, or get information out that your building is closed, e.g., can you change your phone message, can you put out a message through TV/radio, post signs?List ways your center can be used to support the community. If you use the building for anything other than what you are licensed for, you will need a waiver from ISDH. Resource ManagementAppendix 6 for contact informationThis may need to be edited if you keep or don’t keep water/pre-packaged foodSafety and SecurityDescribe staff identification processReferences Waste Management Program you should have in placeReferences Isolation/Decontamination/Hazardous Material Policy you should have in place UtilitiesList title of person responsible for facility/utility managementReferences Utility System Failure policy for additional informationContinuity of OperationsList Title of who makes decisions regarding resumption of services. Describe the essential business functions and priority of which to resume first, second, etc. If you have a work-at- home process for any areas, describe that here.List any Memorandum of Understanding (MOU) or Mutual Aid Agreements (MAA) you may have. If you have any, these should be referenced here as an Appendix and added to the appendix list in the Emergency Preparedness Program document. If you don’t have one, but need one, there are sample MOU/MAA templates in the Resource FilesSuccession Planning – Appendix 9 insert your succession plan. At a minimum, you should have one person identified to replace anyone in administration/management. A third alternate is even better. RecoveryCritical Incident Stress Debriefing - Appendix 6 should include mental health professionals you can contact if needed. Another option may be clergy.Physical Environment – identify title(s) of who should complete this task, multiple people may be indicated.Incident Evaluation – References Emergency Preparedness Program where it describes the process for this under the Training and Testing Program section. If you make any changes to a plan and/or policy and procedure then you should design your next exercise to include a task that will test the change to make sure it is munication PlanThe communication plan further details out information regarding communication with partners and sharing of information. It includes the following sections and edits/actions you must take to customize to your center.Title PageProvide your centers specific name. you may also want to include your address.Add the effective date (date approved by your standard processIntroduction – no changes neededAuthority and Spokesperson – Identify title of who has authority for communicationIn this area, you would list your codes related to emergency preparedness and describe them briefly. It is recommended that you use plain language versus color codes. There is a sample of plain language codes in the resource file.Identify title of primary and back-up spokesperson. You could have one person for media and one person for other communication. Stakeholders – no action needed unless you have additional stakeholders to munication Principles – no action needed.ASC contact information – Appendix 5 – insert your staff roster / call back list.Partner Contact Information – Appendix 6 – complete and insert the contact list as this appendix.Modes of Communication – No edit neededInsert statement regarding 2-way radios, if you have them and describe if they are used daily in normal operations, or if you have them specifically for use during an emergency. If that is the case, describe where the radios are located, who would use the radios, and process for distribution. If you do not use 2-way radios, delete reference to them.Edit if you use 800 MHz radios, LiveProcess, and/or WebEOC. If you use any of these, explain who has access, where to find the log-on information for LiveProcess or WebEOC. If you have any instructional manuals for any communication system, reference that and attach to the plan. In the near future, a user guide for radio etiquette and general use, as well as instructional guides for LiveProcess and WebEOC will be made available in the resource rmation Sharing – no edits neededPatient Information Release – no edits neededPatient Condition/Location Information – no edits neededASC Abilities and/or NeedsIndicate if you have made or attempted contact with hospital and name the hospital(s)Edit regarding your access to 800 MHz radio, LiveProcess, WebEOC.Media Plan Indicate if you have a website and/or Facebook Emergency Tracking SystemThis policy and procedure explains how you can track the location of your staff, volunteers, patients, and visitors throughout an incident. It includes the following sections for edits/actions you must take to customize to your center.Header - Policy should be copied and pasted onto your standard policy and procedure template so that it matches your other Center policies. ProcedureIndicate how you track staff on a daily basis - do they clock or sign in/out? Do you have time records? Where do you keep your schedule? Edit list to show the various areas in your center.Attached staff log and scheduled patient log – there are sample forms to use for this. you can select which form you want to use and keep that attachment and delete others. Or you can attach an existing form.If you have the capability to do patient tracking in either or both of these methods, just take out the highlight. Or edit to state which method used, or edit to indicate your specific process for this.Disaster patient tracking log, you can use one of these, or use an existing one. If you use the SMART Triage Tag system, you can leave this language in as well as the attachment regarding the triage tag system. If you do not use the Triage tag system, but would have a disaster chart for each person seen, then reference that here and include the paper record as an attachment, or use the example attached to create one. The resource files include documentation regarding the coding of patients during triage.References the Communication PlanEvacuation Procedure for decision making and process for partial/full evacuation. It includes the following sections for edits/actions you must take to customize to your center.Header - Policy should be copied and pasted onto your standard policy and procedure template so that it matches your other Center policies. ProcedureAttachments for Decision to Evacuate and process for making decision when you have warning and when there is no warning. You may need to play with the boxes/text size on the decision trees to make all the words fit on the page when you print it out. References the attachment for various types of carrying techniques. You can delete and/or add to this attachment based on the techniques you have trained your staff on. Even if you are on one floor, you may still need to carry someone out if your building is damaged and you have non-mobile and/or injured individuals to evacuate.describe types of equipment and/or processes you would use to evacuate individuals needing mobility assistance if you are a multi-level facility. If you are all on one level, you may not have any of these devices, but could still use them to move a person on the same level. If you do have them, make sure you describe their location and reference an instructional manual or procedure to use. And make sure your staff are properly trained to use any lift/moving equipment.Identify location where you would stage people until transportation arrives. You should identify both an internal and external location. You should already have a transfer agreement in place with at least one hospital. Include the name of that hospital here and Appendix 7 should be a copy of that agreement.Emergency Tracking System policy is referenced for how to track location of patients and staffReferences Communication plan to explain information that is shared related to evacuation.Order of Patient Evacuation – The Resource files includes information related to the Triage Transportation – indicate if you have any agreements/contracts with private ambulance companies and include that agreement in the munication – References Communication Plan to supplement this policy.Shelter-In-PlaceProcedure for decision making and process for protecting staff and/or patients through a shelter-in-place process. It includes the following sections for edits/actions you must take to customize to your center.Header - Policy should be copied and pasted onto your standard policy and procedure template so that it matches your other Center policies. ProcedureReferences Communication Plan for additional informationa., b., and c. Identify and list safe areas within your facility (does not necessarily have to be in your center if you lease space in a larger building). c. indicate title of person who is responsible for turning off the air handling system and/or the HVAC system.e. References Emergency Tracking System for tracking staff, patients, others during the shelter-in-place processReference Evacuation policy for process to use if shelter-in-place is changed to evacuation orders.Indicate title of person who can manage air quality /HVAC system.Medical Documentation SystemYour center should already have in its policies and procedures a process for managing medical records as this is one of the Indiana rules and regulations. If so, you should just be able to add information to that policy related specifically to emergency preparedness. There are suggested language you can add related to storage, back-up systems for electronic medical records, references to the Communication Plan for sharing of patient information, maintaining a medical record for anyone presenting to the center during a disaster, safe movement of medical records, and security of medical records. Utility System FailureProcedure for how to recognize a system failure, who to contact, and briefly what to do until repairs are made. It includes the following sections for edits/actions you must take to customize to your center.Header - Policy should be copied and pasted onto your standard policy and procedure template so that it matches your other Center policies. ProcedureThe table should be edited as follows: Include the phone number of the facilities person or the information systems person as indicated.If you do not have an elevator in your building, you should delete those sections.For electrical power failure, if you do not have a generator, delete that reference and the reference about alternate sources of fuel.If you do not have a centralized nurse call system, delete that section.If you do not have medical vacuum, delete that section. You need to establish and document in this policy the time frame for how long following interruption of service, the facilities person should contact the appropriate vendor/repair person. It is a good idea to have a list of vendors/repair companies for each of these utility systems and describe that and attach that list to this policy in case the facilities person is unable to make contact.According to the CMS interpretive guidelines, vendors should be held accountable for timely repairs and/or support of your facility during an emergency situation. Any contract you have should include this language. Volunteer ManagementProcedure for on-boarding volunteers in a disaster situation. It includes the following sections for edits/actions you must take to customize to your center. It is recognized that most centers would close during a disaster and volunteers would not be a situation to be dealt with. However, CMS requires a policy and procedure on volunteer management in care of a large scale disaster possibly where the ASC would be tasked through an emergency declaration process to stay open. Most likely, if this is the case, you would be working with your county Emergency Management Agency, the Local Health Department, and/or the District Healthcare Coalition Partners (Red Cross) to manage this. Header - Policy should be copied and pasted onto your standard policy and procedure template so that it matches your other Center policies. ProcedureThis is the recommended statement regarding use of volunteer, but you may choose to edit it. References Disaster Credentialing Procedure that you should already have. This should also be discussed in your Medical Staff Bylaws and Rules and Regulations. (There is a sample policy in the Resource Files if you need to develop a Disaster Credentialing Procedure.)Indicate how you would identify volunteers with badges/vest/hats, etc. References Emergency Tracking System, where there are forms for tracking volunteers. Make sure you have all volunteers sigh in/out on a time log.Alternate Role of ASC WaiverProcedure discussing guidance of alternate uses of an ASC during a declared disaster. It includes the following sections for edits/actions you must take to customize to your center.Header - Policy should be copied and pasted onto your standard policy and procedure template so that it matches your other Center policies. ProcedureReferences information already discussed regarding this in the Emergency Preparedenss Program, the EOP, and the Evacuation policy.As part of the Healthcare Coalition and valued business in your community, you should have already discussed potential alternate uses with your EMA, local health department, nearby hospitals, and/or district healthcare coalition. If not, please take an opportunity to reach out to these folks ASAP to do so. They will need to know what your capabilities are in order to include you in preparedness process in the event of a major disaster. Once that has been determined, you can add that to this policy. AppendicesDocumentation of Coordination/Collaboration – Documentation of this (or an attempt to do this) is required. Each ASC is encouraged to communicate with their county Emergency Management Agency, their local health department, and nearby hospitals to discuss ways the ASC can be of assistance during a disaster situation. This information should also be shared with the district Healthcare Coalition. You are encouraged to submit a letter to each of these organizations, but more importantly to have a face to face meeting for this discussion. A sample letter is attached. For this appendix, you should attach any actual letters you have submitted. Any written correspondence or meetings should be documented in your safety committee minutes. Hazard Vulnerability Analysis (HVA) – two different tools are included that you may select from. If you are part of a healthcare network system, your center must also complete an HVA and submit it to the system. Documentation of annual review of your HVA is required. Once you have completed your HVA, include it as Appendix 2. Member to document your collaboration with community partners. Exercise examples and observation tools – There are 10 exercise scenarios in these files. Each has an observation/critique tool attached. There are 7 tabletop exercises, 1 functional exercise, and 2 full-scale exercises. CMS requires at least one full-scale exercise and 1 tabletop exercise per year and in order to meet the regulations for the November 2017 date, each ASC must have completed 2 exercises within the past 12 months. If you are Joint Commission or HFAP accredited, both exercises must be operationally based (functional or full-scale – a tabletop exercise will not meet their requirements). The ASC is strongly encouraged to conduct these exercises with community partners; this can be the hospital, the health department, the emergency management agency, the local emergency planning council, and/or the district healthcare coalition. If this is not feasible, you must document why and can then conduct a facility-only based exercise. If you have activated your EOP for an actual event in the past 12 months, that event can take the place of one of these exercises.After Action Report (AAR) – this must be completed following each exercise or response to an actual event. A template for completing the AAR is included. The process for completing an AAR is explained in the Emergency Preparedness Program under the section for Training and Testing. A written AAR should be kept for at least 3 years.Employee Contact List – Include your staff roster with contacts as Appendix 5. Make sure to update this frequently. Healthcare Coalition and Local Contact Information – Included here is a listing of various agencies that you should have contact information for. A map of how ISDH divides the state into districts is also included. For your final document, include the map provided and your own list of contacts (adding to the ones listed here). In the Resource files, you will find a document from ISDH that lists the healthcare coalition district chairs and co-chairs. These are the people you would typically contact if you have an incident and need to report it to or ask assistance from the district healthcare coalition. In order to obtain information regarding Healthcare Preparedness Program representatives for public health as well as the epidemiologist for your district, contact the ISDH. Your healthcare coalition or county emergency management agency may be able to assist you in providing contact information for any of the additional agencies on the contact list. Once your list is completed, include it as Appendix 6 along with the district map (Appendix 6.1)Transfer Agreement – include here any written transfer agreements you have with hospital(s). ASC Organizational Chart – include your center’s organizational chart here.Succession Plan – as part of your continuity of operations, you must have a succession plan. This is a listing of who can take over if someone is not able to function for an extended period of time. The best practice is to have at least 2 back-ups for every administrative/management position (primary and secondary). Include your succession plan as Appendix 9.HICS Information – Included here are several documents. 10.1 is a modified HICS organizational chart for the incident management team (IMT) that can be used for smaller facilities. You may still never fill all of these positions and in the Emergency Operations Plan, it is recommended that 3 positions be filled (Incident Commander, Operations Section Chief, and Logistics Section Chief) Included as Appendix 10.2 are job action sheets for these 3 positions. Remember if other positions are not filled, then the Incident Commander must assume those duties, or assign them to the Ops Section Chief or the Logs Section Chief. Resource Inventory List – this should include inventory of medical supplies.Call-back Ready Kit – this is an information sheet that you can discuss and provide to your staff for items they should have on-hand if they are called in to work on an emergency basic. Disaster Supply Toolkit – is a list of items that you should consider for a toolkit/tote to keep resources needed to manage an incident.Back-up Paper Medical Record – this is only applicable if you have electronic health records. Include a copy of your paper chart and any instructions for doing paper charting.Alternate Care Site Agreement – if you have an agreement with another ASC, hospital, or other medical facility to perform services in case your center is closed for an extended period of time, include that here. There are some samples of agreements for this in the Resource Files.Evacuation Map – include a map showing the evacuation routes.Resource FilesThis file includes information that will be of value to your center, but is not included in the Emergency Preparedness Program document, the Emergency Operations Plan, the Communication Plan, or the policies and procedures. It includes at this point the following documents:Crosswalk for CMS-AAACH-JC-HFA-NFPACrosswalk for Surveyor for CMS regs to EP Tags ASCDisaster Privileges – EXAMPLE POLICYDistrict Hospital Chairs and Co-Chairs, 2017.05.16Example Infectious Disease Information for Ambulatory CareExample Infectious Disease PolicyExample Plain Language Paging System ScriptingExample Plain Language CodesHICS Command Staff Job Action SheetsHICS FormsHISC General Staff Job Action SheetsHICS Guidebook 2014HICS Med Tec Job Action SheetsHICS Support Aides Job Action SheetsLiveProcess Emergency Manager User GuideRadio Use and EtiquetteSample MOU for Alternate SiteSample MOU for evacuation processSample Mutual Aid AgreementSample Mutual AssistanceTriage AssessmentWebEOC 8.3 User GuideAdditional Information may be added to these Resource Files from time to time.Training ProgramThe Training Program folder includes the following.PowerPoint presentations that you can use to train your staff for initial activation of this toolkit, new hire orientation, and annual education. For Part 1 and 2, you can use these as PowerPoint presentations and provide an instructor to “read” the narrative notes for each slide, adding additional information based on your specific ASC. Or you have the option to use the Media Player version which has the narration already completed and you are available to add information or answer questions. For Part 3 you must edit this PowerPoint to make it specific to your ASC. The policies and procedures that were developed for this toolkit are included already along with suggested narration, but you MUST include other policies and procedures you have developed for your ASC, e.g., severe weather, security threats, earthquakes. Part 3 must be done as an interactive presentation.Part 1 – Emergency Preparedness ProgramPart 2 – Emergency Operations Plan and Communication PlanPart 3 – Policies and ProceduresStaff Competencies Checklist for Emergency Preparedness – This is an example of a document that can be used to demonstrate emergency preparedness knowledge. Surveyors will be asking how you demonstrate staff knowledge. Suggestions for continued review of emergency preparedness for staff – This explains what is required based on CMS rules and offers suggestions for how to accomplish on an ongoing basis.Acronyms (Refer to the Emergency Preparedness Program for definitions of these acronyms)AAAHCAccreditation Association for Ambulatory Health CareAARAfter Action ReportASCAmbulatory Surgery CenterCfCConditions for CoverageCFRCode of Federal RegulationsCMSCenter for Medicare and Medicaid ServicesEMAEmergency Management AgencyEOPEmergency Operations PlanHFAPHealthcare Facility Accreditation ProgramHVACHeating, Ventilation, Air ConditioningISDHIndiana State Department of HealthMAAMutual Aid AgreementMHzMegahertzMOUMemorandum of UnderstandingTJCThe Joint Commission ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download