PREPARE Disaster Plan Template and Guidelines

PREPARE

Disaster Plan

Template and

Guidelines

August 2008

Developed by Mather LifeWays with funding from the

Assistant Secretary for Preparedness and Response. To

learn more about Mather LifeWays disaster preparedness

programs, go to prepare.

TABLE OF CONTENTS

PAGE

Organization Information ....................................................................... 3

Introduction to the Plan .......................................................................... 4

Facility Preparation ................................................................................ 4

Authorities and References.................................................................... 5

Emergency Response Roles ................................................................. 5

Job Action Sheet .................................................................................... 7

Communication Plan and Resources .................................................... 8

Emergency Resource Call List............................................................... 9

Staff Call Protocol ................................................................................ 10

Response ............................................................................................. 11

Resident Emergency Profile ................................................................ 14

Resident Tracking System ................................................................... 15

Sample Mutual Aid and Transfer Agreement ...................................... 17

Surge Capacity Plan ............................................................................ 18

Security/Safety Issues.......................................................................... 22

Evacuation ........................................................................................... 23

Re-Entry ............................................................................................... 26

Post-Disaster Recovery ....................................................................... 26

Information , Training and Exercise ..................................................... 27

Plan for Updating the Disaster Plan ..................................................... 27

Examples of Polices and Procedures .................................................. 28

Definitions............................................................................................. 28

Fire ....................................................................................................... 29

Skilled Nursing Care Evacuation ......................................................... 30

Apartment Evacuation.......................................................................... 32

Severe Weather ................................................................................... 33

Bomb Threat ........................................................................................ 35

Discontinuation of Water Supply .......................................................... 37

Electrical Power Outage ...................................................................... 38

Heat and Humidity................................................................................ 39

Radiological Accident ........................................................................... 40

Chemical Spill ...................................................................................... 41

Bioterrorism Threats............................................................................. 42

Internal Disaster ................................................................................... 48

PREPARE Disaster Plan Template and Guidelines

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DISASTER PLAN TEMPLATE AND GUIDELINES

DISASTER PLAN TEMPLATE AND GUIDELINES

The following document serves as a template to assist your long-term care organization to plan and prepare to

meet the needs of both your residents and staff in the event of a disaster/emergency. The Disaster Plan is

compliant with current federal guidelines for disaster planning (National Incident Management System). Your state

and local emergency preparedness agencies will also be key resources to your organization for guidance and

information about local plans to integrate into your Disaster Plan. Your Disaster Plan should be shared with local

emergency preparedness and government agencies to assure your local first responders are aware of your plans.

---------------------------------------------------------------------------------------------------------------------ORGANIZATION INFORMATION

Organization:

Address:

City:

Phone Number: (

State:

)

Zip code:

Fax: (

)

Owner of LTC Community/Organization

Name:

Address:

City:

State:

Phone Number: (

)

Cell Phone Number: (

)

Zip code:

Fax: (

)

E-mail:

Administrator/Executive Director

Name:

Address:

City:

State:

Phone Number: (

)

Cell Phone Number: (

)

Zip code:

Fax: (

)

E-mail:

PREPARE Disaster Plan Template and Guidelines

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DISASTER PLAN TEMPLATE AND GUIDELINES

I.

INTRODUCTION TO THE PLAN

PURPOSE: To continue providing quality care to residents of (name of your community)

during times of

major emergencies and/or disasters or when such events are reasonably believed to be pending by maintaining

close coordination and planning links with local emergency response organizations on an ongoing basis.

It will be the responsibility of the highest ranking staff person on duty to declare a situation a disaster and activate

the disaster and evacuation policy and procedure.

A disaster may be classified as a fire, tornado, flood, electrical power outage, explosion, bomb threat, hazardous

material spills or releases, or any other situation that would warrant evacuation of the community in order to protect

the lives and safety of residents and staff.

This disaster/emergency plan is implemented under the following circumstances:

II.

FACILITY PREPARATION

Physical Plant Risk Assessment is completed _________________ (indicate frequency ¨C quarterly, biannually,

annually).

Physical Plant Risk Assessment Schedule:

Physical Plant Risk Assessment includes (develop checklist for these items):

?

?

?

?

?

?

?

?

Clearly marked gas and water shut-off valves with legible instructions how to shut off each

Available tools to facilitate prompt gas shut-off

Check gas shut off-valves and generators to insure proper operation

Evaluate heating, ventilating, and air conditioning function and control options

Assess ducted and non-ducted return air systems

Building air tightness

Preventive maintenance of HVAC system

Community¡¯s evacuation plan in area accessible to the public

Photographs of buildings needed for insurance purposes have been taken on

located

.

and are

A plan to have Protected Cash on hand is in place (specify plan).

PREPARE Disaster Plan Template and Guidelines

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DISASTER PLAN TEMPLATE AND GUIDELINES

III.

AUTHORITIES AND REFERENCES

Emergency Response Roles

Each role listed in the emergency response Chain of Command has specific duties to perform should the

Emergency Preparedness Plan be implemented. Although there are specific personnel that would be best to fill a

position, they may not necessarily be on site when a disaster might occur; therefore, each job does not necessarily

require a specific person to fill the position.

The following structures parallels the government¡¯s Incident Command System (ICS) outlined in the National

Response Plan. This clarifies key functional areas that need your attention when responding to

emergencies/disasters. Using the ICS conforms to the state Emergency Management System which increases the

likelihood of your organization¡¯s eligibility for reimbursement of disaster-related costs.

In addition, one person may need to take responsibility for the functions of more than one job until relieved. The

main priority is to begin the functions until additional or more qualified personnel are available to fulfill these duties.

In the event the emergency occurs on off-shifts or weekends designate which staff will hold key roles until the

designated personnel arrive on site.

Additionally, if your organization owns or manages more than one LTC community or CCRC and/or you have a

corporate office dedicated to managing more than one community, you must identify responsible personnel for

each community.

Insert your Organizational Chart to outline the Chain of Command with lines of authority for functional

responsibilities and communication. (Depending on the size of the organization some individuals may have more

than one function.)

1. Designated Incident Command Manager and Community Spokesperson - Manages the overall response

and communications with the external community (generally filled by the organization¡¯s chief

administrator/executive director)

Name:

Phone Number: (

E-mail:

)

Cell Phone Number: (

)

2. Succession Incident Command Manager - Responsible for Incident Command in the event the initial

designee is unable to assume responsibility.

Name:

Phone Number: (

E-mail:

)

Cell Phone Number: (

)

3. Operations Manager ¨C Directs carrying out of the initial response functions including delegation of other

functions (i.e., utility checks, fire suppression, search and rescue, and first aid).

Name:

Phone Number: (

E-mail:

)

Cell Phone Number: (

PREPARE Disaster Plan Template and Guidelines

)

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