APPENDIX F:

APPENDIX F:

EMERGENCY PREPAREDNESS PLAN

POLICY

The Ship Group Community Services will establish and maintain an Emergency Preparedness Program designed to manage 

the consequences of natural disasters or other emergencies that disrupt the agency's ability to provide care.

PURPOSE

To conduct business normally, it is important for the agency to have a strategy on preparation for emergencies. This plan 

provides an organizational structure so that the agency can effectively prepare for both external and internal disasters that can 

negatively affect its environment of care.

STRUCTURE

The Ship Group Community Services Care plays an important role as a provider of care to the residents of its community. 

The agency is ready to assist as needed in case of community emergency, and as appropriate integrates its Emergency 

Preparedness Plan with community disaster plans, as appropriate, to support the community’s response to a disaster. The 

organization will train its personnel in this plan.

The scope of this agency emergency plan, both internal and external, will determine the role of the branch or its personnel in 

responding to an emergency. The agency will participate in at least two emergency preparedness drills per year as required 

by Joint Commission standards.

The Program Director, in collaboration with the Program Coordinator, will tailor the branch-specific Emergency Preparedness 

Plan using the corporate template.

This plan contains processes for preparedness, response, mitigation, and recovery in the event of an emergency.

Mitigation activities are those a health care organization undertakes in attempting to lessen the severity and impact a potential 

disaster or emergency may have on its operation while preparedness activities are those an organization undertakes to build 

capacity and identify resources that may be utilized should a disaster or emergency occur. An example of mitigation is, if an 

agency’s Hazard Vulnerability Analysis determined that the branch was vulnerable to flooding and completed building 

construction to add exterior drainage to reduce the likelihood of future flooding this would be an example of mitigation.

As a first step in preparing an effective emergency preparedness plan The Ship Group Community Services prepares a Hazard 

Vulnerability Analysis (HVA). This analysis assists our organization in determining where it is most vulnerable to 

emergencies. Completion of the HVA is our organization's first step in the development of mitigation strategy. A sample 

HVA is included in this plan. 

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DEFINITIONS 

External Disaster: A civil catastrophe, either manmade or caused by an act of God. An external disaster may overwhelm 

normal facilities. This condition can occur as a result of fires and explosions, storms, civil disorders, multiple injury accidents, 

military action, among other causes

Internal Disaster: An event such as a fire or explosion resulting in internal casualties or circumstances. If the situation requires 

the evacuation of patients, such evacuation will be coordinated with emergency service personnel from the fire and police 

agencies.

It is the responsibility of the Program Director or his or her designee to activate the Emergency Preparedness Plan.

In the event that total evacuation of the branch is necessary, the Program Coordinator or his or her designee will assume the 

responsibility for branch evacuation. Each consumer will be rated as to the type of transportation necessary: 

▪ Ambulatory 

▪ Ambulatory with assistance 

▪ Wheelchair.

If an internal disaster disables the branch’s essential utility services, the Program Director will determine whether a contracted 

service will be used so that reserve utility provisions such as emergency power can be provided. Emergency power will be 

limited to providing temporary lighting so staff can perform essential functions, such as securing the doors of the clinic, 

backing up computer data, and obtaining urgent medical data to provide to a primary care physician.

COMMUNICATIONS 

All communication, both within and outside the branch, will be coordinated through the administrative assistant’s desk in the 

patient waiting room, as directed by the Program Director and Program Coordinator.

RADIOACTIVE OR CHEMICAL ISOLATION AND DECONTAMINATION 

If an occurrence involves radioactive materials or hazardous chemical spills requiring outside assistance, the Program 

Director or Program Coordinator will contact the licensed and certified hazardous waste contract provider. State radiation 

safety authorities will also be contacted in accordance with State law.

DISRUPTION OF SERVICES AND MANAGEMENT OF SPACE, SUPPLIES, COMMUNICATIONS, 

AND SECURITY 

If a portion of the branch is incapable of supporting patient care but total evacuation is not required, the following procedures 

will be followed:

▪ Space Allocation: Patients will be served in unaffected areas of the branch that are able to safely provide services.

▪ Supplies: The Program Director will be immediately notified of any situation that necessitates an increased level of 

supply items. The existing supply areas will be automatically used to provide supplies to the extent possible.

▪ Communications: Both the phone system and cell phones will be used to provide communications between the branch 

and outside agencies. If a total phone loss occurs, a messenger will be assigned to carry messages back and forth within 

the branch until other arrangements could be made.

▪ Security: Needs that might exceed the capability of branch will be relayed to the local police department or contracted 

security service.

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DISASTER PROCEDURES FOR STAFF MEMBERS 

In the event of either internal or external disaster, the Program Director, his or her designee, or the Program Coordinator can 

initiate the Disaster Call List (telephone tree).

On arrival at the branch, staff members will report to their respective supervisors to log in and be assigned to whatever tasks 

are required: in direct patient care, preparing for evacuation, or other assignment.

If a regular work shift ends during the declared emergency period, all staff members will stay at their respective assignments 

until officially relieved by order of the designee.

All staff members will report changes of address and telephone numbers, as well as their response time to the branch, to the 

Program Coordinator as soon as a change becomes effective. The Program Coordinator will continually update the Disaster 

Call List and provide it to the Program Director, Administrative Assistant, Corporate Office, and other designees.

The manager in charge or designee will verify that personnel are assigned to call the staff members listed on the Disaster Call 

List expediently.

These assignments will be conducted by identified staff members available for this task until the arrival of the Program 

Coordinator.

MANAGEMENT OF PATIENTS IN DISASTER SITUATIONS

If a disaster or an emergency involves the branch or staff members, all less-than-essential services will be temporarily 

modified or discontinued until the situation allows for resumption of full program ability. The Program Director or his or her 

designee will determine whether these less-than-essential services are to be effected and, if so, when. 

Staff members normally involved in provision of services determined by the Program Director or Safety Officer to be less 

than essential will make themselves available for other duties. These duties may include helping move patients from the 

affected area of branch to an unaffected section. These staff members will also be responsible for providing any patient 

assistance devices to facilitate the movement or evacuation of patients from the branch.

All staff members will be familiar with the overall agency Emergency Preparedness Plan.

Facilitation of patient movements, including admissions, transfers, and control of patient information, will be directed by the 

individual assigned by the Program Director or his or her designee. Information concerning any patient will be released only 

by a Qualified Professional or at the direction of the Program Director.

In disaster or emergency situations requiring additional physicians, the Medical Director will direct those physicians.

ADDRESSING THE MEDICATION NEEDS OF PATIENTS: 

The branch / agency maintains a 24-hour telephone answering capacity. This is accomplished through the following 

processes:

At 5:01 pm on weekdays, the main phone lines are forwarded to an answering service with a live operator that dispatches 

crisis calls to the First Responder on-call. The operator attempts to patch the call director to the First Responder and in the 

event the call cannot be patched directly to the First Responder, then the call is handled by another Qualified Professional 

serving as back-up, the Clinical Director, or the Program Director. The answering service maintains a database that includes 

personal contact numbers for on-call and administrative staff as a backup to the on-call cell phone that the First Responder 

carries.

The agency provides the assigned First Responder with the Crisis Book, which contains current treatment plans, medication 

profiles, crisis plans, and driving directions from the office to the home address of patients for emergency purposes. 

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TRAINING OF STAFF IN EMERGENCY PREPAREDNESS PROCEDURES

All branch personnel are made familiar with the disaster, fire, and emergency plans during the orientation process.

EMERGENCY PREPAREDNESS DRILLS

Semiannual drills will be conducted. These drills will be held no more than 7 months apart. Staff members will participate as

necessary to fulfill the requirements for compliance. The drills may involve simulated volunteer patients or using substitute 

packets of information in lieu of patient volunteers. To decrease or eliminate the possibility of staff injuries with simulated 

evacuations, the branch may utilize an information packet describing the patient injury or condition to simulate the actual 

evacuation and actual disaster.

Feedback concerning any type of drill conducted will be reviewed by the Quality Assurance Committee for necessary actions.

For each drill, preparedness and patient management will receive specific attention to evaluate the effectiveness of the policy 

and implementation of policy by staff members.

The Quality Management Director will be responsible for communication to Senior Management of any information or 

recommendations about proposed changes in the emergency preparedness policy. The Quality Management Director will see 

that proposed changes are implemented as specified.

The Quality Management Director will, on a random basis, quiz staff members concerning the Emergency Preparedness Plan 

and their roles in any drill. This process serves as a source of feedback, which the Quality Management Director can use for 

evaluation of the overall effectiveness of the program.

ALTERNATIVE CLINIC SITE

In the event that the branch/clinic cannot open, patients may schedule a follow-up appointment at the next nearest The Ship 

Group Community Services Care branch for ongoing care, including medication management, or request referral to an 

outside agency. Staff that normally works at the closed branch will be reassigned to help provide coverage at an alternate 

branch and assist with patient care coordination until the branch/clinic resumes normal operation.

INTERNAL DISASTER PROCEDURES 

If there is an occurrence (explosion, bomb threat, fire) in which the number of people requiring care exceeds the immediate 

resources:

The Program Director, or Clinical Director if directed, will evaluate the area or program needs, including staff.

Managers will send all available staff to the Program Director for assignment: 

▪ Primary location: Waiting room/reception area, if this area has been compromised then use the secondary location.

Staff members will await further instructions from the Program Director or, if he or she is given authority, the Clinical 

Director.

Staff members will activate the program or service callback list, obtain approximate response times of employees, and have 

employees report to the staffing pool to be assigned as needed.

The program or service will maintain operation as normally as possible.

If additional staff members are necessary, the Program Director will evaluate contacting outside support.

Disaster alert status and function will be maintained until “Emergency all clear” is announced or indicated by the Program 

Director.

BOMB THREAT (CODE GREY)

If a bomb threat is received, the Administrative Assistant and Program Director will be notified immediately. Staff members 

will maintain a calm environment.

All personnel will passively search for items that look out of place but will not move items to search the branch. The bomb 

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squad will do this. Employees will make note of any unusual looking item but will not touch or disturb it in any manner.

The Program Director will prepare an evacuation plan to be initiated on order of the bomb squad or Clinical Director or his 

or her designee.

All personnel will try not to upset patients and will assist in evacuation, if not assigned to other duties by the Program Director, 

Clinical Director or his or her designee.

EXTERNAL DISASTER PROCEDURES

If there is an occurrence in a location other than those listed previously in which the number of people requiring care exceeds 

the immediate resources of the branch:

The corporate branch has designated a fixed location at the patient waiting area, with mobile sites located at a freestanding 

site. The Program Director, his or her designee, or the Clinical Director, will be the person in charge with the following duties:

▪ Approving the implementation of the Emergency Preparedness Plan and evacuations 

▪ Maintaining information flow throughout the branch 

▪ Determining the extent of callback 

▪ Identifying new designated areas if needed and communicating this information to the staffing pool (at the receptionist desk and 

the Clinical Director.

A staffing pool will be located at the receptionist desk in the patient waiting area. The staff conference room or kitchen area 

will be used if the waiting room has been affected by the disaster.

The Program Coordinator or his or her designee will be the person in charge with the following duties: 

▪ Maintaining a log of resources 

▪ Reporting to the staffing pool 

▪ Maintaining a record of assignments made from the staffing pool (who, where, when returned) 

▪ Maintaining a quiet, calm atmosphere 

▪ Communicating needs for personnel to the Program Director or his or her designee 

▪ Communicating availability of services status to the Corporate Branch 

▪ Making program assignments and relaying information to the Administrative Assistant.

An information center will be located at the receptionist desk in the patient waiting room.

The Program Director or his or her designee will be the person in charge with the following duties: 

▪ Maintaining approved information flow to the public 

▪ Maintaining approved information flow to families of people involved in the disaster 

▪ Maintaining the waiting area for patients and visitors

▪ Maintaining and distributing a log for the Red Cross, if appropriate.

If treatment areas are undamaged, they will be used as usual.

EVACUATION PROCEDURE

Immediate Evacuation

▪ First move patients and others who are closest to the danger. 

▪ Separate an emergency area from people by a fire door. 

▪ Move medical records with patients, if possible. 

▪ In event of fire, do not use elevators. 

▪ Lead ambulatory patients to exits using the evacuation plan posted in the area. 

▪ Move non-ambulatory and helpless patients down evacuation route by means of emergency carriers. 

▪ Notify the telephone operator of the nature of the emergency.

Planned Evacuation

Planned evacuation will be initiated by the Program Director or CEO only. The telephone operator or a runner will notify 

the programs or services of need, extent, and timeframe of the evacuation.

Evacuation Areas

The parking lot will be the designated evacuation area except that in inclement weather, the Program Director or Clinical 

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Director will indicate a secondary evacuation area.

FINANCE DISASTER PLAN

▪ All personnel assigned to the finance department will report to the supervisor or the staffing pool. 

▪ At the “all clear” announcement, personnel will resume normal operational functions.

ADMISSION DISASTER PLAN 

▪ One employee will report to the administration area to assist the Administrative Assistant with admissions of new 

patients. 

▪ Updated program/service control will be maintained hourly, and the waiting room receptionist will receive a copy of 

the revised plan. 

▪ The Program Director or his or her designee will be responsible for collection and safekeeping of valuables 

belonging to injured persons. 

▪ Personnel with no specific assignments will report to staffing pool.

BUSINESS OFFICE DISASTER PLAN 

▪ One employee will report to the Program Director to assist at the information center. 

▪ All other in-direct personnel in the branch will report to the staffing pool.

STAFFING DISASTER PLAN 

▪ All personnel will remain at clinic. 

▪ Available staff will assist the assigned staff member in callbacks of employees at the direction of the Corporate 

Branch

▪ On completion of callbacks, available staff will report to the staffing pool and will be prepared to take over the 

leadership role of the staffing pool if needed. 

▪ At the “all clear” announcement, staff members will return to modality or service operations.

STAFF AND STAFF FAMILY SUPPORT ACTIVITIES

This plan acknowledges that the staff of this organization is one of our greatest assets. If staff or staff family members are 

directly impacted by a community emergency or disaster, the branch leadership will be sensitive to this and attempt to 

ameliorate this. Support of impacted staff and families may include: referrals to disaster relief organizations and referrals for 

incident stress debriefing. The Program Director will be available to discuss any staff or family needs based on staff family

impact or community emergency or disaster.

MEDICAL RECORDS 

▪ All personnel will report to the front office and await further instructions.

PERFORMANCE STANDARDS 

Performance standards for this plan will include, over time: 

▪ Emergency preparedness knowledge and skill for staff 

▪ Completion of two emergency preparedness drills per year 

▪ The level of staff participation in emergency preparedness management 

▪ Monitoring and inspection activities 

▪ Emergency and incident reporting procedures that specify when and to whom reports are communicated 

▪ Inspection, preventive maintenance, and testing of applicable equipment 

▪ Use of space 

▪ Replenishment of supplies 

▪ Management of staff

At least one specific performance standard in this plan will be identified for measurement at any given time.

ANNUAL EVALUATION

An annual evaluation of the effectiveness of the Emergency Preparedness Plan undertaken at The Ship Group Community 

Services willinclude performance measures, using the previous year’s quarterly reports; recommendation from the corporate 

governance; and input from staff and other relevant sources of safety outcome sources. This evaluation will include statistical 

trends. These reports will be presented to the Quality Assurance Committee by the Quality Management Director.

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Agency leadership will prioritize opportunities for improvement in this function.

Annual Evaluation of the Effectiveness of the Emergency Preparedness Plan

Instructions: The Quality Management Director will facilitate an interdisciplinary team of branch subject matter experts in evaluating the 

effectiveness of this plan during the past year. This team will use quantitative and qualitative data to support its conclusions. This report 

should be typed, using the identified format and headers. The report should be completed within 30 days of the beginning of the year. It 

should be submitted within 45 days of the beginning of the year to the Quality Assurance Committee and Senior Management Team. It 

should be sent to the Administrative Director within 60 days of the beginning of the year.

EVALUATION OF OBJECTIVES OF PLAN

How effective was the Emergency Preparedness Plan in meeting its identified objectives? (Attach a copy of supportive data, 

including drill critiques.)

Objective A: Establish an Emergency Management Program to provide an effective response to disasters or emergencies 

affecting the environment of care: 

Objective B: Maintain an Emergency Management Program to provide an effective response to disasters or emergencies 

affecting the environment of care: 

Objective C: Drills are conducted semiannually (plan is executed in response to planned drills or an actual emergency, at 

least 4 months apart): 

EVALUATION OF THE SCOPE OF PLAN

Did the scope of the plan effectively include all the operations of the agency, including implementation of procedures in 

response to disasters; role with community-wide emergency preparedness efforts; notifying external authorities; assigning 

personnel; managing space, supplies, and security; evacuation, if needed; alternate sites for care; managing patients; operating 

the backup communication system; and orientation and education of staff?

EVALUATION OF STAFF EMERGENCY PREPAREDNESS TRAINING

List types of emergency preparedness training that occurred, number and percentage of staff who received training, specific 

outcome scores of post-testing, and supervision observations after training.

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EVALUATION OF PERFORMANCE OF PLAN

How successful was the branch in meeting its emergency preparedness related performance standards for the year? What was 

the most significant safety accomplishment of the plan last year? (Attach copies of Environment of Care Performance 

Measures data for the year and any reports done by outside agencies, including insurance companies, county-wide emergency 

response agency, law enforcement, fire department, or The Joint Commission, that evaluate the emergency preparedness of 

the environment of care of the branch.)

EVALUATION OF EFFECTIVENESS OF PLAN

How effective was the plan in preparing the clinic for internal and external disasters?

CONCLUSIONS AND RECOMMENDATIONS FOR THE PLAN FOR THE NEXT YEAR

What are the most important recommended areas of emergency preparedness for the plan and clinic to address during the 

next year? Have any financial resources been asked for or committed to any of these recommendations?

Report presented to the Quality Assurance Committee on (date): 

Report completed by: Date: