NORTHPOINTE BEHAVIORAL HEALTHCARE SYSTEMS



REVISIONS TO POLICY STATEMENT: YES NO OTHER REVISIONS: YES NO

APPLICATION:

All staff and contractual providers.

POLICY:

It is the policy of Northpointe Behavioral Healthcare Systems (NBHS) that:

A. Northpointe shall define its role and response in community wide emergency preparedness plans as herein determined and in concert with the Emergency Operation Plan for Dickinson, Iron and Menominee County.

B. Procedures are established which identify staff responsibilities and functions, and management of service recipients during natural or man-made emergencies.

C. Staff training appropriate to their responsibilities is provided, and planned evacuation techniques occur related to the organization’s response to emergencies.

PURPOSE:

A. To maximize the management of the consequences of natural disasters or other emergencies.

B. To provide direction to staff in order to enhance their ability to respond to natural disasters or other emergencies.

C. To ensure compliance with the Department of Community Health, Department of Human Services, and/or the current Accreditation Body standards, policies and/or procedures.

DEFINITIONS:

A. Emergency Preparedness Log – A log designed and maintained at the building site for the recording of dates, tests, or drills performed consistent with this policy and procedure.

B. Employee – Any individual employed on a regular full, part-time, and (relief) basis by NBHS who provides direct services and/or care to mental health service recipients.

C. NBHS Contractors’ Staff – Any individual employed on a regular full, part-time and (relief) basis who provides direct services and/or care to mental health service recipients.

D. NBHS Occupied Buildings – Buildings and/or structures occupied and operated by Northpointe employees working under the direction and supervision of the Chief Executive Officer.

E. NBHS Lease Facilities – Buildings and/or structures under contract with Northpointe for the purpose of directly or contractually providing mental health services and/or programs to service recipients.

F. Congregate Care Center – A designated location at which housing and food are provided for people who have been evacuated.

G. Disasters – Natural or manmade events that cause major disruption in the environment of care, such as damage to the organization’s buildings and grounds due to severe wind storms, tornadoes, hurricanes, floods and earthquakes; or the impact of service recipient/individual care and treatment activities due to such things as the loss of utilities (power, water, telephone) due to floods, riots, accidents or pandemic.

H. Pandemic – Global outbreak of disease that occurs when a new virus that can spread easily from person to person.

I. Isolation – Precautionary measure used in the care of persons with a communicable disease. The person is confined to a designated area until no longer a source of infection.

J. Quarantine – Restriction placed on entering or leaving a premises where a case of communicable disease exists. (Protects the healthy individuals).

K. Reverse Quarantine – Close facilities to visitors.

L. Command Control Function – That part of the documented management plan for emergency preparedness that is specific to the settings and services provided by the organization’s processed for delineating who is responsible for activating and managing the coordination and direction of what must be done to effectively deal with a situation.

M. Lock Down – Emergency protocol to prevent people and/or information from escaping or entering the facility. A Partial Lockdown is restricting the entire facility. A Full Lockdown is restriction of movement between areas within the facility.

STANDARDS:

A. All Northpointe occupied buildings and/or lease facilities shall have Safety Committee approved emergency procedures for the following emergencies: Building evacuation, tornado watch/warning, floods, bomb threats, utilities failure, medical, lock down, workplace violence, pandemic/psychiatric emergencies, terrorism/bio terrorism and nuclear or toxic leak disasters. (Fire Emergency Procedures are dealt with in its own separate policy – See Fire Prevention and Emergency Plan.

B. All Northpointe occupied buildings shall, under the auspices of the Safety Committee, implement the plans on a semi-annual basis either in response to an emergency or a planned drill.

C. The Safety Committee shall review the results of any implementation of an emergency plan and shall submit its findings, and resulting recommendations, if applicable, to the Quality Improvement Committee.

D. Training for emergency procedures consists of the following:

1. Each new employee is responsible for reading Northpointe’s Emergency Preparedness Plan and Safety Policy and Procedures in addition to this policy. All supervisors or program directors will ensure that both are available to the employee and they have a clear understanding of their role and responsibility.

2. The Emergency Preparedness Plan(s) is implemented semi-annually, either in response to an emergency or in a planned drill activity.

3. Individual, instructions and training will be offered to those employees particular to the types of emergencies.

E. The documented management plan(s) is specific to the settings and services provided by the organization and includes, as appropriate to the organization’s processes for:

1. Establishing, supporting and maintaining an emergency preparedness management program.

2. Responding to a variety of disasters or emergencies, both within the organization and in the surrounding community.

3. Integrating the organization’s role with the community wide emergency preparedness efforts.

4. Notifying proper authorities outside the organization of an emergency.

5. Reliably notifying staff of an implementation of the emergency preparedness plan.

6. Providing an emergency communication system during disasters and emergencies.

7. Evacuating the total facility if the organization’s environment cannot continue to support adequate service recipient care and treatment.

8. Establishing an alternate care site if the organization’s environment cannot continue to support adequate service recipient care and treatment.

9. Identifying, where appropriate, available facilities for radioactive or chemical isolation and decontamination.

10. Managing service recipients during disaster or emergencies, including the scheduling of services and staffing, control of individual information, admissions, transfer and discharge.

11. Delineating and activating the command control function.

PROCEDURES:

A. Procedure for building evacuation, tornado watch/warning, floods, bomb threats, work place violence, utilities failure, medical, pandemic/psychiatric emergencies, lock downs, terrorism/bio terrorism and nuclear or toxic leak disasters shall be developed for each Northpointe occupied building and/or lease facility. These procedures shall be submitted to the Safety Committee for its approval and retention in the sites Plant Technology and safety management record and shall identify at the minimum:

1. Specific information detailing roles, responsibilities, and functions of staff.

2. Responsibilities and functions of service recipients and visitors.

3. Provisions to be provided for individuals in case of emergency, including in case of evacuation, location, equipment or supplies, and means of communication, the contingent method of communication and the method of obtaining supplies and equipment during disasters or emergencies.

4. Staff training and service recipient drills, if applicable, including a written emergency preparedness log. The information and skills needed to perform the required responsibilities of the emergency preparedness plan.

B. The Safety Committee shall review and approve all emergency preparedness plans.

C. Upon Safety Committee approval, a copy of each plan shall be maintained in the plan technology and safety management records.

D. Orientation and ongoing training shall be provided to all NBHS employees or NBHS contract employees. This training shall be documented and submitted to the Board’s training coordinator on an ongoing basis and shall be entered in the appropriate personnel files. Additionally, the training documentation shall be maintained in the site’s training file for review during semi-annual site reviews.

E. There shall be semi-annual drills conducted and documented on each building’s Emergency Preparedness log. This documentation shall be submitted to the Maintenance Manager for Safety Committee review on a quarterly basis. Staff members who participate in implementing the emergency preparedness plan(s) can describe and/or demonstrate:

1. The emergency preparedness program’s goals and performance standards;

2. The training they have received in the emergency preparedness plan(s);

3. Their roles and responsibilities during implementation of the emergency preparedness plan(s);

4. Their roles and past participation in organization-wide drills;

5. The organization’s contingent method of communication fueling disasters and emergencies;

6. The method of obtaining supplies and equipment during disasters or emergencies.

F. In the event of an agency wide computer outage which is expected to last for an extended period of time, staff will be notified by the IT Team via intercom announcement and/or telephone. The IT team will immediately set up laptops at each office so that clinical services can continue. All non-clinical staff should report to their immediate supervisor for directions.

REFERENCES:

State of Michigan, Department of Human Services, Licensing Rules and Adult Foster Care Small Group Homes

Current CARF Accreditation Manual

Northpointe Safety Committee

Northpointe Emergency Plan

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