STEP 1: Identify a temporary meeting place outside your facility in case a sudden building-wide evacuation is necessary.

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1 PLANNING WORKSHEET: Evacuation Directions: Use this worksheet to help your facility develop a plan for evacuation for localized emergencies affecting your facility and nearby areas. STEP 1: Identify a temporary meeting place outside your facility in case a sudden building-wide evacuation is necessary. You need a safe meeting place outside the building or rally point where you can gather residents and staff to do a headcount and assure that everyone is accounted for. Choose a meeting place that is: A safe distance from the facility, but within walking distance. Protected from rain, wind, and snow if possible. Out of the way of vehicle traffic and fire department apparatus. A neighboring business, church, or school might be a good option for a temporary evacuation destination if it is close. However, you will need 24 hour access to the location. You would like the space to be adequate for a short stay (several hours at least). DESCRIBE YOUR TEMPORARY MEETING PLACE HERE: STEP 2: Identify sites for a long-term evacuation Identify at least two locations where you can take your residents if your facility is shut down. Keep in mind that your staff are probably going to have to take care of the residents in this new location. Therefore, one evacuation site should be located nearby in your town or community. If there s an emergency that affects only your facility, you can move residents to this location. The other site should be farther away, in case a disaster affects your entire community. One of the best choices for an evacuation site is another long-term care facility, because it is already set up to handle the unique needs of long-term care residents. Check your licensing regulations to see if there are specific requirements related to evacuation sites.

2 Be sure you have written agreements with your evacuation sites. Be sure your sites can handle all the residents you need to relocate. If your facility is large, you will likely need agreements with multiple facilities. When you develop a mutual aid agreement with another facility, be sure to document: The timeframe for answering an emergency request for help; The number of residents the facility can temporarily accept; How long they can stay; Arrangements for physician and staff temporary privileges; The cost per resident and how and when you will pay for them; Materials and supplies staff should bring to the new facility; Materials and supplies the new facility will provide; The cost for those supplies; and The role of your staff. It s a good idea to have a legal professional review the document to be sure the expectations of both parties are clear. Also, find out under what circumstances your licensing agency may allow you or your host facility to go over capacity. Find out whether this is permitted, and also who to contact if it might become necessary. LIST YOUR LONG-TERM EVACUATION SITES (including contact, address and phone number): Print out primary and alternate directions to your evacuation sites and include them in your plan. STEP 3: Identify how to transport residents and your staff. Find out if your community has an evacuation plan and who coordinates that plan. Make a list of the types and numbers of vehicles you will need. Will any of your residents need to be moved in ambulances?

3 Will you need vehicles that are wheelchair accessible? How many vehicles of each type will you need? Before calling transportation vendors, make a list of questions to ask. Here are some suggestions: Will you have enough vehicles to handle all of your commitments if a disaster strikes our entire community? How long will it take to get vehicles? How much advance notice will you require? Will your vehicles accommodate residents in wheelchairs? Are your drivers trained to transport people with special needs? Get a written contract from each transportation vendor and be sure the contract documents your requirements. Try to get agreements with several vendors, in case your primary vendor is unavailable. Your licensing regulations may have specific requirements related to transportation agreements. If you are having trouble securing a transportation contract, be sure to document your failed attempts to show licensing inspectors you are making a good faith effort. You should also notify your local emergency manager to see if he or she can assist you with governmentcontracted vehicles. Local officials will need to know that you have made an effort to secure transportation but that you may need assistance with this part of your emergency plan. DESCRIBE YOUR TRANSPORTATION METHODS HERE: (include contact, address and phone number for vendors if appropriate)

4 STEP 4: Identify how to identify and track residents during and after transport. Describe your strategies for identifying and tracking residents during and after transport below. Are you going to use wristbands? How will you track residents in each vehicle? We ve provided some examples in our sample Evacuation Guide. Be sure to check your regulations for specific information that MUST be transported with each resident. Decide in advance how this information will be organized and transported. STEP 5: Identify supplies, records and equipment for the evacuation. Describe how you identify and pack resident s personal supplies for a long-term evacuation.

5 Describe your methods for transporting and protecting medications. (How will it be packaged/ transported? How will you administer medications on the transport vehicle? Who is responsible for getting it ready and transporting it?) Look back at the list of emergency supplies you developed earlier in the training. Which of these emergency supplies will you need to transport to the evacuation site? What supplies/equipment will already be available at the site? Make a detailed list of supplies you will need to transport. Describe your methods for transporting additional supplies, such as food/water, etc.. (How will it be packaged/ transported? Who is responsible for getting it ready and transporting it?)

6 If appropriate for your facility, describe your methods for providing critical resident care during prolonged transports, including: Medication administration on time; Sustaining use of ventilators and other critical medical equipment during transport; Turning stretcher residents regularly to avoid skin breakdown and pressure sores, even in relatively short transports; and Assuring that a resident s critical equipment is not separated from the resident to avoid its loss or misplacement during transport (i.e., transport it in the same vehicle as the resident). Describe your methods for informing families of residents and staff of the evacuation and intended destinations. Describe how you will confirm that residents and staff have reached their destinations in an evacuation.

7 Describe your methods for transporting medical records and other important documents. (How will it be packaged/ transported? Who is responsible for getting it ready and transporting it?) In an evacuation, how will you keep records with the individual resident in case they become separated from your staff in the process of evacuation? Make a list of the types of other supplies you will bring on the transport vehicle to keep residents safe and comfortable during the journey. Food/snacks; describe: Water Incontinence briefs Blankets

8 YOUR NEXT STEP: Use the information you ve assembled in this worksheet to develop your Evacuation Guide. Include the Guide in your Emergency Operations Plan. Refer to the sample Emergency Operations Plan to view a sample Evacuation Guide.