PLACER COUNTY HEALTHCARE SURGE & ALTERNATE CARE SITE PLAN

Transcription

1 PLACER COUNTY HEALTHCARE SURGE & ALTERNATE CARE SITE PLAN March 10, 2008

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3 PLACER COUNTY SURGE / ACS PLAN Acknowledgements Placer County Alternate Care Site / Healthcare Surge Steering Committee Members Karl Pedroni American Medical Response Richard Burton, MD Placer County Department of Health and Human Services Mitch Hanna, CEO Sutter Auburn Faith Hospital Lisa Davies Chapa-De Indian Health Program Rui Cunha Placer County Office of Emergency Services Pat Brady, CEO Sutter Roseville Medical Center Debbie Aspling, CEO Kaiser Roseville Medical Center Victoria Pinette Sierra-Sacramento Valley EMS Agency Shawn C. Joyce Sierra-Sacramento Valley EMS Agency Placer County Alternate Care Site / Healthcare Surge Advisory Committee Members Karl Pedroni American Medical Response Michael Romero, MPH Placer County Department of Health and Human Services Jill Meeh, R.N. Sutter Auburn Faith Hospital Lisa Davies Chapa-De Indian Health Program Richard Simmons Placer County Office of Emergency Services Barbara Todd, R.N. Sutter Roseville Medical Center Tom Jones Kaiser Roseville Medical Center Shawn C. Joyce Sierra-Sacramento Valley EMS Agency Consultant Services Douglas Buchanan Consulting Page ii

4 PLACER COUNTY SURGE / ACS PLAN TABLE OF CONTENTS INTRODUCTION...vi A. Background... vi B. Project Oversight... vi C. Purpose... vi SECTION I I. PLACER COUNTY COMMUNITY SURGE PLAN...1 II. HOSPITAL SURGE TEMPLATE DHS L&C Temporary Permission for Increased Patient Accommodations Request Worksheet...35 SECTION II I. ALTERNATE CARE SITE ACTIVATION...1 A. Definitions...1 B. Authority...1 C. Liability...1 D. Policy Triggers Standard of Care Organization Structure Action Plan ACS Closure Medical Record / Documentation Storage Patient Information...4 E. Procedure Notification Incident Action Plan ACS Facility Assessment Equipment and Supply ACS Closure...6 F. Attachments ACS Management Team Directory ACS Medical Record ACS Patient Charge Capture (Appendix H) HICS Form Facility Status Report (Appendix C)...77 SECTION III I. ACS STAFFING PLAN...1 Page iii

5 PLACER COUNTY SURGE / ACS PLAN A. Purpose...2 B. Policy ACS HICS Structure Staffing Requests Emergency Credentialing of Medical Staff Medical Staff Bylaws Maintaining Personnel Scope of Practice & Professional Liability...4 C. Procedure Assessment of Workforce Need Augmenting the Workforce Receiving and Organizing Personnel Incident Command Structure Demobilization of Personnel...7 D. Attachments Matrix for ACS Estimated Staffing Levels Medical Resource Request Form (Appendix F) HICS Form Section Personnel Time Sheet (Appendix C)...77 SECTION IV I. ACS SUPPLY PLAN...1 A. Purpose...2 B. Policy ACS HICS Structure Assessment of Resources Inventory Management Board of Pharmacy Waiver...2 C. Procedure Resource Requests Inventory Management Resource Tracking Demobilization of Resources...4 D. Attachments ACS Equipment Supply Matrix (Appendix I) Medical Resource Request Form (Appendix F) HICS Form Resource Tracking (Appendix C)...77 SECTION V I. ACS SECURITY PLAN...1 A. Background...2 B. Purpose...2 C. Policy...2 D. Procedure Security Plan Staffing Receiving and Organizing Personnel...4 Page iv

6 PLACER COUNTY SURGE / ACS PLAN 4. Demobilization of Personnel...5 F. Attachments HICS Branch Assignment Form 204 (Appendix C) HICS Communications Plan- Form 205 (Appendix C) HICS Resource Accounting Record- Form 257 (Appendix C)...77 SECTION VI I. PATIENT MOVEMENT...1 A. Purpose...2 B. Policy Transfering Patients to an Alternate Care Site...2 C. Procedure Patient Movement...3 D. Attachments Patient Transportation Worksheet HICS Disaster Victim / Patient Tracking Log - Form 254 (Appendix C)...77 SECTION VII I. APPENDICES...1 A. ACS HICS Organization Chart...2 B. ACS HICS Job Action Sheets...3 C. HICS Forms...77 D. Target ACS Facility Assessments E. SAMPLE MOU for Use of Facilities in the Event of a Mass Medical Emergency F. Medical Resource Request Form G. Placer County Healthcare MOU H. ACS Patient Charge Capture I. ACS Equipment / Supply Matrix Page v

7 PLACER COUNTY SURGE / ACS PLAN INTRODUCTION A. Background Medical surge capacity refers to the ability to evaluate and care for a markedly increased volume of patients challenging or exceeding the normal capacity of a hospital or healthcare system. Individual hospitals plan for and routinely handle surge requirements resulting from seasonal fluctuations in respiratory ailments, environmentally based conditions, and community incidents. In Placer County, as throughout most of California, hospitals routinely operate at or near capacity. Moderately-sized incidents are handled in accordance with the Region IV Multi-casualty Incident Plan. Patients are transported to hospitals throughout the county and throughout the region to avoid overloading any single hospital. However, very largescale incidents or widespread disease outbreaks may overwhelm the capacity of all hospitals and other healthcare providers in a region. Responding to such incidents requires the close coordination and cooperation of hospitals, community clinics, governmental agencies, and other healthcare providers. B. Project Oversight A multi-disciplinary Steering Committee and Advisory Committee comprised of representatives from local hospitals, clinics, ambulance service, Public Health, EMS Agency, and OES were formed to provide input and guidance in the development of the Community Surge and ACS plans, policies, and procedures. The Steering Committee, comprised of facility administrators, provided overall direction and final approval of all documents. The Advisory Committee, comprised of the Emergency Preparedness Coordinators from participating facilities, provided the primary input and feedback during each phase of the document development. C. Purpose The purpose of this plan is to provide a framework for the management of medical surge needs resulting from an incident that overwhelms the capacity of hospitals in Placer County and nearby counties in order to meet the overall goal of minimizing mortality and morbidity. As the demand for healthcare services increase and existing healthcare facility assets become exhausted, the local or state government will have to step in and establish government authorized Alternate Care Sites (ACSs) to absorb the patient load until the local healthcare system recovers from a Level III or Level IV Surge Event. Page vi

8 PLACER COUNTY SURGE / ACS PLAN Page vii

9 PLACER COUNTY SURGE / ACS PLAN Placer County Surge Plan D. Community Surge Plan. 1 E. Hospital Surge Template. 14 SECTION 1: SURGE PLAN Section I: Page 1 of 35

10 PLACER COUNTY SURGE / ACS PLAN COMMUNITY SURGE PLAN A. DEFINITIONS 1. Control Facility is the facility designated by the EMS Agency to monitor hospital capacity and capability and to assume primary responsibility for directing patient destinations by ambulance during a Multiple Casualty Incident or Healthcare System Surge Event. 2. Healthcare Surge Event means a proclamation by the local health officer or other appropriate designee, using professional judgment determines, subsequent to a significant event or circumstances, that the healthcare delivery system has been impacted, resulting in an excess in demand over capacity and/or capability in hospitals, community care clinics, public health departments, other primary and secondary care providers, resources, and/or emergency medical services. The local official uses the situation assessment information provided from the healthcare delivery system partners to determine overall local healthcare jurisdiction/operational area medical and health status. 3. Level I Surge (Yellow) means that most hospitals within the county are experiencing a surge and are able to manage the situation with the assistance of the Control Facility or waivers for normal patient care services. 4. Level II Surge (Orange) means, the hospitals in the county require participation of additional healthcare assets (e.g. clinics, public health, long term care, etc.) to contain the situation; and regularly scheduled planning sessions or conference calls are necessary in order to strategize, coordinate, collaborate, and communicate among all community healthcare providers, EMS agency, Public Health, Fire, and OES coordinators. 5. Level III Surge (Red) means healthcare providers within the county are not capable of meeting the demand for care, and assistance from outside the Operational Area is required. A local Healthcare Surge Event has been proclaimed. Regional, or statewide coordination is necessary in order to meet the medical and health needs of the public. 6. Level IV Surge (black) means the healthcare providers within the Operational Area are not capable of meeting the demand EMS and hospital standards of care must be recalibrated using pre-approved altered standard of care protocols, and less-acute hospital patients should be triaged from hospitals to appropriate alternate care providers. Statewide or national coordination is necessary. Section I: Page 2 of 35

11 PLACER COUNTY SURGE / ACS PLAN 7. Medical/Health Operational Area Coordinator (MHOAC) means the Public Health Officer and local EMS Agency Administrator or designee who is responsible, in the event of a disaster or major incident where mutual aid is requested, for obtaining and coordinating services and allocation of resources within the Operational Area (county) border. B PURPOSE 1. To prevent the escalation of Healthcare Surge and mitigate its impact on the healthcare community by developing a system for appropriate distribution of available resources during a system overload or disaster. 2. To provide healthcare managers, and emergency managers with timely and accurate information that allows them to mitigate current or pending hospital resource or capacity deficiencies. 3. To augment standard EMS System MCI Policies and Procedures. C POLICY 1. OPERATIONAL AREA PLANNING AND PREVENTION a. Public and private-sector agencies should coordinate planning to minimize the impact of predictable events. Emergency planning is always eventspecific because the characteristics of each emergency are different. However, there are general concepts that are applicable in most emergencies. Some of these concepts are articulated in this section. b. Agencies responsible for operational functions, planning, coordinating, or that are elements of a critical/high-risk infrastructure should work cooperatively to prevent or mitigate the impact of a natural or man-made disaster. c. Agencies should verify the availability of equipment and supply caches before an incident. Agencies should always assure that supplies are maintained at desired par-levels. d. Agencies should establish a Joint Information Center (JIC) before an incident to provide coordinated and focused public education and information messages. These messages should provide the public with credible direction or other actionable information that decreases their reliance on scarce resources. Section I: Page 3 of 35

12 PLACER COUNTY SURGE / ACS PLAN e. Public and private-sector first responders and first receivers should receive just in time training in topics relevant to the incident. f. All organizations should assure that emergency operations plans, phone numbers, and staff call back trees are current. Update documents as time allows. g. All organizations should assure that local and state government agency contacts are current. Key contacts include the Placer County Health Department, MHOAC, Sierra-Sacramento Valley EMS Agency (S-SV EMS), Placer County Office of Emergency Services, the Control Facility, and State Department of Health Services, Licensing and Certification. Maintain 24/7/365 contact information. Note-The Placer MHOAC is a shared position between the Placer County Health Officer and the Regional Executive Director of S-SV EMS. The MHOACs can be reached during business hours at their respective agencies or after hours through the Placer County Sheriff s Department dispatch center. h. All agencies should verify that they are prepared to provide critical capabilities and functions. 2. HOSPITAL PLANNING AND PREVENTION a. Hospitals should work closely with other hospitals within their corporate structure to determine the status of critical hospital services within their regional service area. b. Hospitals should work with their corporate organization to develop preincident inter-facility staffing reciprocity agreements and post-incident expedited credentialing capacity among their corporate facilities. c. All hospitals should implement recurring training in disaster and emergency operations, to include HICS, ICS, SEMS, NIMS, Haz- Mat/Decontamination, and the hospital s emergency operations plan. D PROCEDURE 1. Responses to Healthcare System Surge are organized into four distinct levels. The procedures in this Section are generally applicable to most Healthcare System Surge incidents; however, because each incident has its own unique characteristics, hospitals, Local EMS Agency, Control Facility, Dispatch, and EMS personnel are always required to use their best professional judgment to respond to emergency and disaster situations. a. LEVEL I SURGE: (Yellow) Section I: Page 4 of 35

13 PLACER COUNTY SURGE / ACS PLAN i. CRITERIA Criteria for Level I Surge includes: Two or more hospitals within the system experiencing a sudden unexpected increase in the number or severity of patients, and have announced an internal Level I Surge. ii. IMPACTED HOSPITAL(S): Notify the Control Facility of status change. Update facility status in EMSystem to Advisory (including reason for Level I Surge) and provide additional updates every two hours, or as requested by Control Facility. Initiate or continue with internal hospital surge policies. iii. NON-IMPACTED HOSPITAL(S): iv. MHOAC ED charge nurse will receive Level I notification from Control Facility via EMSystem. ED charge nurse monitors status in their ED. Investigate/confirm capacity of service(s) in facility. Update facility status in EMSystem and provide additional updates every two hours or as requested by Control Facility. Consider activation of internal hospital surge policies. Consider establishing ongoing planning sessions/coordination with all potentially impacted agencies/facilities. Consider site visits of hospitals to verify statuses and Level I activities. v. CONTROL FACILITY Assess capacity and capability of other hospitals within county. Section I: Page 5 of 35

14 PLACER COUNTY SURGE / ACS PLAN Consider assessing capacity and capability of neighboring counties (Sacramento Regional EMSystem Zones 1-7), when appropriate. Notify MHOAC, hospitals, Local EMS Agency, dispatch providers, and ambulance providers of Level I Surge in system. Coordinate all patient distribution per Patient Distribution Manual of OES Region IV MCI Plan until Surge level indicators have been resolved. vi. DISPATCH PROVIDERS Notify supervisors and ambulances providers of Surge Level I activation in system. vii. AMBULANCE PROVIDERS Contact Control Facility for destination decisions. b. LEVEL II SURGE: (Orange) i. CRITERIA Criteria for Level II Surge includes concurrence of two or more EMS or hospital providers that regularly scheduled planning sessions are necessary to mitigate the impact of the surge. ii IMPACTED HOSPITALS Take any actions not previously completed for Level I Surge. Emergency Department to notify appropriate personnel Level II Surge. ED Director and house supervisor respond to ED to assess critical hospital services and supplies. Attempt to forecast event. Update Facility Status in EMSystem at least every 2 hours or as requested by the Control Facility. Consider activating HICS structure. Consider contacting DHS Licensing and Certification for staffing and bed capacity flexibility. Section I: Page 6 of 35

15 PLACER COUNTY SURGE / ACS PLAN Augment hospital s staff, i.e. alternate staffing schedules, consider call-back staff, and receive staff from corporately-related hospitals. House Supervisor evaluates the need to use outpatient and recovery room to house admissions House Supervisor approves placement of new admit in hallway of inpatient department that will admit patient. Hospital Administration should consider cancellation of elective procedures. Participate in community medical/health planning sessions/coordination. iii OTHER HEALTHCARE PROVIDERS (non-hospital) Consider activating internal emergency response plans. Consider augmenting staff, i.e. alternate staffing schedules, consider call-back staff. Participate in community medical/health planning sessions/coordination. Monitor EMSystem and CAHAN as requested by MHOAC. iv. MHOAC Take any actions not previously completed for Level I Surge. Attempt to forecast trend of impaction. Determine capability and capacity for critical hospital services at all hospitals within the county. Notify County Health Officer and EMS Agency Duty Officer. Notify OES Director. Coordinate community medical/health planning sessions/coordination for as necessary. Section I: Page 7 of 35

16 PLACER COUNTY SURGE / ACS PLAN Consider requesting activation of Operational Area EOC. Consider activation of county-specific volunteer program or state ESAR-VHP program. Consider requesting activation of JIC. Coordinate Risk Communication messages with Public Health Department, including: advisory messages to the medical/health community, media updates, etc. Consider request for declaration of local state of emergency. Monitor capabilities and status of ambulance providers. Consider need for alternate medical triage for 911 medical aid requests and austere care protocols for field EMS personnel. Evaluate the need for additional health/medical resources: 1. Ambulance Strike Teams. 2. Hospital Staff. 3. Equipment/Supplies. Prioritize Medical Resource Requests. Prioritize Medical Transportation Requests. Notify RHDMC. v. CONTROL FACILITY Take any actions not previously completed for Level I Surge. Determine available capacity for critical hospital services at all hospitals within the county, Sacramento Regional EMSystem Zones 1-7 and communicate with the Regional Control Facility regarding patient distribution to other Region IV hospitals if needed Notify hospitals, EMS Agency, dispatch providers, and ambulance providers of Level II Surge. Section I: Page 8 of 35

17 PLACER COUNTY SURGE / ACS PLAN If appropriate to situation, direct ambulances to non-impacted destinations, based on service capability. Standby consider additional staffing for future operational periods. vi. DISPATCH PROVIDERS Notify EMS Providers of Level II Surge Status. If appropriate to situation, hold or direct non-emergency interfacility transfers with the objective of developing additional critical hospital service capacity. Consider adding additional staff for potentially increased volume of EMS System calls and interfacility transfers. vii. AMBULANCE PROVIDERS Contact Control Facility for destination decisions. Upon request of MHOAC, staff and deploy additional ALS, BLS, and Critical Care Units for potentially increased volume of EMS System calls and interfacility transfers. If appropriate to situation, hold or direct non-emergency interfacility transfers with the objective of developing additional Critical Hospital Service capacity. Add additional staff for increased volume of EMS System calls and inter-facility transfers. c. LEVEL III SURGE: (Red) i. CRITERIA Criteria for Level III Surge includes: Healthcare Surge Event has been proclaimed by the Public Health Officer or designee. ii ALL HOSPITALS Take any actions not completed under Level II Surge. Section I: Page 9 of 35

18 PLACER COUNTY SURGE / ACS PLAN Hospital Command Center will notify appropriate personnel of Level III Surge. Participate in community medical/health planning sessions/coordination. iii. OTHER HEALTHCARE PROVIDERS (non-hospital) Take any actions not completed under Level II Surge. Participate in community medical/health planning sessions/coordination. iv. MHOAC Take any actions not completed under Level II Surge. Determine available capacity for critical hospital services at all hospitals within the county. Coordinate community medical/health planning sessions/coordination for: 1. Attempted forecasting of the duration and impact of the event 2. Coordination of personnel, resource, and supply needs 3. Recruitment of community medical personnel and volunteers 4. Activation of alternate care sites Evaluate the need for additional health/medical resources: 1. Personnel: Cal-MAT, DMAT, CMV 2. Equipment/Supplies : Ambulance Strike Teams Mobile Field Hospital Pharmaceutical Caches, Strategic National Stockpile (SNS) v. CONTROL FACILITY Determine available bed capacity at all hospitals within the county, Sacramento Regional EMSystem Zones 1-7, and communicate Section I: Page 10 of 35

19 PLACER COUNTY SURGE / ACS PLAN with other Control Facilities within Region IV regarding patient distribution as needed. Coordinate additional bed capacity needs with the MHOAC. Consider additional staffing for future operational periods. vi. DISPATCH PROVIDERS Notify EMS Providers of Level III Surge Status. Consider adding additional staff for potentially increased volume of EMS System calls and interfacility transfers. vii. AMBULANCE PROVIDERS Contact Control Facility for destination decisions. If appropriate to situation, hold or direct non-emergency interfacility transfers with the objective of developing additional Critical Hospital Service capacity. Upon request of MHOAC, staff and deploy additional transport resources for potentially increased volume of EMS System calls and interfacility transfers. d. LEVEL IV SURGE: (Black) i. Criteria for Surge Level IV includes: Altered or Austere Protocols have been adopted by the local coalition of healthcare providers in order to adapt to the increased demand. ii. ALL HOSPITAL(S) Take any actions not taken under Level III. Hospital Command Center will notify appropriate personnel of Level IV Surge. Participate in community medical/health planning sessions/coordination for: Section I: Page 11 of 35

20 PLACER COUNTY SURGE / ACS PLAN 1. Implementation of Alternate or Austere Medical Protocols. iii. OTHER HEALTHCARE PROVIDERS (non-hospital) Take any actions not completed under Level III Surge. Participate in community medical/health planning sessions/coordination for implementation of Alternate or Austere Medical Protocols. iv. MHOAC Take any actions not completed under Level III Surge. Determine available capacity for critical hospital services at all hospitals and Alternate Care Sites within the county. Participate in community medical/health planning sessions/coordination for: 1. Altered levels of care. Consider public recruitment of licensed professional volunteers to assist hospitals. Prioritize requests for medical and health assets. Notify RHDMC. v. CONTROL FACILITY Notify hospitals, dispatch providers, and ambulance providers of Level IV Surge in system. Add additional staff for increased volume of EMS System calls and inter-facility transfers. vi. DISPATCH PROVIDERS Notify EMS Providers of Level IV Surge status. Implement triage and altered response protocols as directed by the MHOAC. Section I: Page 12 of 35

21 PLACER COUNTY SURGE / ACS PLAN Add additional staff for increased volume of EMS System calls and inter-facility transfers. vii. AMBULANCE PROVIDERS Contact Control Facility for destination decisions. Implement triage and altered response protocols as directed by the MHOAC. Upon request of the EMS Agency, staff and deploy additional ALS, BLS, and Critical Care Units for increased volume of EMS System calls and inter-facility transfers. Add additional staff for increased volume of EMS System calls and inter-facility transfers. Section I: Page 13 of 35

22 PLACER COUNTY SURGE / ACS PLAN Section I: Page 14 of 35

23 PLACER COUNTY SURGE / ACS PLAN Placer County Hospital Surge Plan Template This Hospital Surge Plan Template was developed by the Placer County Healthcare Surge Advisory Committee to assist the hospitals within Placer County. This document was intended to be a template only, and not the final Hospital Surge Plan. The numbers, percentages, floor plans, and other internal operation references depicted within this document are for reference only and should be customized by each facility within Placer County. Revised: 2/15/08 Section I: Page 15 of 35

24 PLACER COUNTY SURGE / ACS PLAN Table of Contents Section Page Purpose 16 Assumptions 16 Definitions 17 Surge Capacity and Rationale 20 Surge Level Activation 21 Inpatient and Triage Surge Factors 26 Hospital Surge Locations 27 Appendix Section Topic Tab Section Patient DECON Capacity (HAZMAT) Planning Pg 31 DHS L&C Temporary Permission for Increased Patient Accommodations Request Form Pg 33 Emergency Supply Inventory Hospital Emergency Room Surge Floor Plans Hospital Inpatient Care Surge Floor Plans TBD TBD TBD Section I: Page 16 of 35

25 PLACER COUNTY SURGE / ACS PLAN A. Purpose: The purpose of this Surge Plan is to develop a systematic approach toward providing patient care services during surge events that may affect our community and hospital. As a leader in patient care services, we are in the best position to respond to a community wide medical crisis. For this reason, we have developed a surge plan that outlines how we intend to respond to support such an event. Our goal is to assess, plan, and implement operational strategies and processes outlined within this document that would enable us to support a Surge event. This plan provides surge strategies intended to supplement existing HIGH CENSUS / CAPACITY DEMANDS policies. B. Assumptions: The development and implementation of this plan is based on the following assumptions: 1. Surge occurs when we have achieved maximum census (Licensed Bed Levels) for either Inpatient or Emergency Department Services. 2. A Surge event will require the Hospital to declare an Internal Disaster, therefore initiating elements of our Emergency Management Program. 3. The Placer County Health Officer will acknowledge the surge and declare a local Medical Disaster/Emergency for level III surge events. 4. Standards that outline Life Safety Codes and other Environment of Care will be deviated from in order to set-up Alternative Patient Care Sites. NOTE: The intent of assumption 4 is not to degrade patient care services, but to provide exceptions that would allow life saving medical services to be provided during emergency crisis situations. 5. The Medical Center is not directly affected by an emergency event (fire, bomb, etc.), and is physically capable of providing basic utility services (Water, Sewage, and Electricity). 6. Adequate staffing is available as determined by Administration. 7. The hospital may exceed the surge plan levels reflected within this document only if capable before declaring a level III surge. Section I: Page 17 of 35

26 PLACER COUNTY SURGE / ACS PLAN C. Definitions: Alternative Patient Care Location (Internal) CAHAN Control Facility (CF) Donor Facility EOC EMSystem Healthcare Facility Indicators HCC HICS Impacted Health Care Facility JIC Level I Surge Designated or non-designated locations used throughout the hospital property where a patient care bed will be set-up that is not designated as a licensed care location. California Health Alert Network (CAHAN) The web-based CAHAN system is designed to broadcast warnings of impending or current disasters affecting the ability of health officials to provide disaster response services to the public. The Control Facility (CF) must be operational 24 hours a day. The CF uses the County med-net radio system. Primary back up system is the Blast phone, cell or satellite phone. The CF is that entity responsible for the dispersal of patients during all Multi-Casualty Incidents (MCI). The CF will collect a Status Report (MCM #408) from all receiving facilities and notify them when patients have been dispersed to them. The healthcare facility that provides personnel, pharmaceuticals, supplies or equipment to a facility experiencing a medical disaster. The Emergency Operations Center (EOC) - the location established by each city or county to centralize coordination of all aspects of a disaster response. An Internet-based hospital system used by all area hospitals to report status (open/closed/diversion) and bed capacity in real-time. Data request and reporting via EMSystem can reach all hospitals simultaneously. A set of healthcare facility resource measures that are reported to MHOAC during a disaster drill or actual disaster. The indicators are designed to catalogue healthcare facility resources that could be available for other healthcare facilities during a disaster. Hospital Command Center (HCC). An area established in a healthcare facility during an emergency that is the facility's primary source of administrative authority and decision-making. Hospital Incident Command System (HICS). The incident command structure developed to meet the needs of the hospital response to a disaster. The healthcare facility where the disaster occurred or disaster victims are being treated. Referred to as the recipient healthcare facility when pharmaceuticals, supplies, or equipment are requested or as the patient-transferring healthcare facility when the evacuation of patients is required. Joint Information Center (JIC)- The location established for the purpose of coordinating the release of information to the press, media and general public. The hospital will participate in providing information to the JIC and help to convey a unified message developed for release to the public. Level I Surge means a surge in patients presenting to the Emergency Department or Inpatient Setting resulting in significant stress to hospital resources, not requiring waivers for normal patient care services. Level II Surge Level II Surge means a surge in patients affecting all local medical providers, requiring regularly scheduled planning sessions or conference calls in order to strategize, coordinate, collaborate, and communicate among all community medical/health providers, EMS agency, Public Health, Fire, and OES representatives. Level III Surge Level III Surge means a surge in patients exceeding the local facilities capability of providing Alternative Patient Care, requiring the activation and Section I: Page 18 of 35

27 PLACER COUNTY SURGE / ACS PLAN utilization of medical resources from the regional agencies. Level IV Surge Master Mutual Aid Agreement Medical Disaster MHOAC OES Region IV Multi-Casualty (MCI) Plan Partner ("Buddy") Patient-Receiving Facility Patient Transferring Facility Participating Hospitals Public Health Department Operations Center (PH DOC) Recipient Facility Level IV Surge means a surge in patients requiring the assistance from State and Federal Agencies. The California Disaster and Civil Defense Master Mutual Aid Agreement made and entered into by and among the State of California, its various departments and agencies of the State, in The agreement provides for support of one jurisdiction by another. An incident that exceeds a facility's effective response capability or that facility cannot appropriately resolve solely by using its own resources. Such disasters will very likely involve local and regional Control Facilities, the local MHOAC and may involve loan of medical and support personnel, pharmaceuticals, supplies and equipment from another facility, or the emergent evacuation of patients. Medical Health Operational Area Coordinator (MHOAC) An individual appointed by the County Health Officer and LEMSA Administrator who is responsible in the event of a disaster or major incident where mutual aid is requested, for obtaining and coordinating services and allocation of resources within the Operational Area (county) as defined in Region IV Manual 3 Medical Health Mutual Aid. The MHOAC 24-hour contact number is: (530) Placer Co PSAP, Fax (530) Placer OES The current OES Region IV Multi-Casualty (MCI) Plan is comprised of 3 interdependent manuals: Manual I MCI Field Operations; Manual II MCI Patient Dispersion (Control Facility Operations); and Manual III Medical Health Mutual Aid. The designated facility (or healthcare system) that a healthcare facility communicates with as a facility's "first call for help" during a medical disaster (developed through an optional partnering arrangement). The healthcare facility that receives transferred patients from an impacted facility responding to a disaster. When patients are evacuated, the receiving facility is referred to as the patient-receiving healthcare facility. An impacted facility -- The healthcare facility that evacuates patients to a patientreceiving facility in response to a medical disaster. Healthcare facilities that have fully committed to the MOU. This list of Participating Hospitals shall be maintained and disseminated by the MHOAC. The center established by the Placer County Health and Human Services Department for coordination of medical and health operations during a disaster or state of emergency. The impacted facility. The healthcare facility where disaster patients are being treated and have requested personnel or materials from another facility. Section I: Page 19 of 35

28 PLACER COUNTY SURGE / ACS PLAN Regional Control Facility The Regional Control Facility (RCF) will operate under the same guidelines as a county CF. The State of California is divided into six regions for purpose of mutual aid during emergency situations. Region IV consists of eleven counties: Alpine - Amador - Calaveras - El Dorado - Nevada -Placer Sacramento - San Joaquin - Stanislaus - Tuolumne - Yolo Regional Disaster Medical Health Coordinator (RDMHC) Regional Disaster Medical Health Specialist (RDMHS) Operational Area The Regional Control Facility (RCF) must be operational 24 hours a day. The RCF uses MedNet for radio communications. Primary back up systems are other redundant communication systems. A volunteer local health officer, EMS agency Coordinator of Emergency Services or EMS agency administrator jointly appointed by the Directors of the California Department of Health Services (DHS) and the Emergency Medical Services Authority (EMSA) based upon the recommendation of the local health officer for a mutual aid region. The role of the RDMHC is to plan for and coordinate medical and health resources within one of California s sic mutual aid regions during times of disaster or other major event requiring medical or health mutual aid. An individual selected by a local EMS agency, under contract with EMSA and California Department of Public Health, as a staff function to coordinate preparedness activities, and assist the RDMHC in coordinating services in the event of a disaster or in the event that medical mutual aid of some type is requested. The operational area is the intermediate level of the state emergency services organization consisting of a county and all political subdivisions within the county geographic area. Section I: Page 20 of 35

29 PLACER COUNTY SURGE / ACS PLAN D. Surge Capacity and Rationale: Each facility will plan for the following capacity during a surge event: Facility Current Inpatient Beds Percent of Increase* Total Inpatient Surge Capacity Sutter Auburn Faith % 155 Sutter Roseville % 300 Kaiser Roseville % 296 Rationale used for planning our Surge Capacity, was based on a Pandemic event, with a 35% Gross Attack Rate, using the maximum scenario admission rates. Reference: CDC, Flu Surge Version 2.0 planning document. We also factored in the 2006 Placer County Population Estimates from the California Department of Finance: Age Group (years) Population , , ,784 *Percentage of Surge increase was based upon the 2006/07 percentage of inpatient beds within Placer County. This methodology was approved by the Placer County Health & Human Services on May 14, 2007 during a Planning meeting with the County. Inpatient bed numbers and population figures to be updated every 5 years, beginning in Placer County Cumulative Data Adult Beds: Hospital Type of Bed Date reported Total licensed Beds Average Daily Occupancy Pandemic Surge Increase (% beds within the county X peak surge) + (average Census) Sutter Auburn Faith Sutter Roseville 2/21/06 Critical care/monitored beds General medical surgical beds (Unmonitored) 2/24/ % x =155 Surge Capacity or 68% Plan for 155 Capacity Critical care/monitored beds General medical surgical beds (Unmonitored) % x =300 Surge Capacity or 79% Plan for 300 Capacity Kaiser 2/23/06 Critical care/monitored beds General medical surgical beds (Unmonitored) % x =296 Surge Capacity or 89% Plan for 296 Capacity. TOTAL NOTE: Based on a 35% Attack Rate using the CDC guidelines, with a peak admission of 393. Section I: Page 21 of 35

30 PLACER COUNTY SURGE / ACS PLAN E. Surge Level Activation: 1. LEVEL I SURGE (local): a. Triggers i. >30 minute delay in Emergency Department triage; or ii. >30 minute delay in Ambulance turn-around times at ED; or iii. Determination by the House Supervisor and on-call Administrator that Level I is necessary. b. Activation i. ED staff shall immediately notify the House Supervisor when any of the above triggers have been met. ii. The House Supervisor shall assume the role of Incident Commander and notify the Nurse Administrator on-call of the Level I Surge. c. Determine Size and Scope i. The House Supervisor shall work with the Nurse Administrator on-call to complete a high level assessment of the potential operational impact on the facility and determine the need to activate the Hospital Command Center (HCC). ii. House Supervisor or designee shall determine the risk and need for a facilitywide lockdown and work in collaboration with Plant Operations to ensure immediate actions to implement the lockdown. iii. The House Supervisor shall conduct regularly schedule meetings with ED and Inpatient Managers to address patient throughput issues and assess needs. d. Internal Alert i. The House Supervisor or designee shall contact the Switchboard Operator, providing any pertinent information about the announcement to be made. ii. The Switchboard Operator will announce THREE TIMES over the public address system: (Note: If a Drill, please identify as a Drill. ) ATTENTION PLEASE. CODE TRIAGE: LEVEL I. e. Staffing i. The House Supervisor shall immediately assign available staff to support the Emergency Department ii. Consider activation of staff call-back iii. Consider implementation of staffing ratio flex f. Bed Capacity i. (Level I Diagram) Available gurneys shall be brought to the Emergency Department by the Lift Tech or designee. g. Communicate ED/Hospital Status Section I: Page 22 of 35

31 PLACER COUNTY SURGE / ACS PLAN i. ED staff shall update EMSystem with current hospital/ed status (e.g. Advisory: Level I Surge ), and keep updated as status /resources change (at least every hour). ii. Nurse Administrator shall notify the Administrator on-call of the Level I Activation. h. Accelerate Discharge i. The House Supervisor, in collaboration with managers of inpatient units, shall identify patients who can potentially be discharged and make the appropriate discharge arrangements with the attending physician and other applicable patient care service providers. 2. LEVEL II SURGE (Local): a. Triggers i. Administrator on-call determines that multi-agency or multi-county coordination is necessary to mitigate the impact on the facility, with possible need for activation of Alternate Care Site(s) ii. Facility has exceeded its licensed bed capacity. b. Activation i. Only the Incident Commander or Nurse Administrator on-call are authorized to activate Level II Surge. ii. The Incident Commander shall activate the HCC, and notify the MHOAC. iii. The Incident Commander or Safety Officer shall determine the risk and need for a facility-wide lockdown and work in collaboration with security (or their designee) to ensure immediate actions to implement the lockdown. iv. Notify Placer County Medical Health Operational Area Coordinator (MHOAC). Share information with MHOAC: Placer County MHOAC: (530) Placer Co PSAP, Fax (530) Placer OES DHS L&C Temporary Permission for Increased Patient Accommodations Request Worksheet. (See page 14 for form and contact information). c. Determine Size and Scope i. The Incident Commander shall develop an Incident Action Plan, and assign HICS positions and activate staff call-back as necessary. d. Internal Alert i. The Incident Commander or designee shall contact the Switchboard Operator, providing any pertinent information about the announcement to be made. Section I: Page 23 of 35

32 PLACER COUNTY SURGE / ACS PLAN ii. Switchboard Operator will announce THREE TIMES over the public address system: (Note: If a Drill, please identify as a Drill. ) ATTENTION PLEASE. CODE TRIAGE: LEVEL II. iii. Switchboard Operator will contact other departments which do not have overhead paging available see list located in area. e. Staffing i. Conduct staff call-back of available personnel as requested by the Incident Commander. ii. Implement staffing ratio flex plan to meet the needs of the patient population. f. Bed Capacity i. Cancel Elective, Routine, or Non-Essential Surgery ii. The Operations Chief shall work in collaboration with Surgery and other assigned departments to assess the needs for cancellation of non-essential elective surgical or interventional services iii. If services are to be delayed or canceled, the managers or designee for the applicable service area shall be responsible to notify the particular physicians those patients being impacted by the change. iv. Expand Inpatient Bed Capacity v. Consider deployment of Surge Tent (alternate triage point, families, etc.) vi. Consider referral of Minor patients to outpatient clinics. vii. Consider utilization of SNFs and other LTC facilities viii. Participate in Operational Area/PH DOC Planning Sessions g. Communicate Status i. ED staff shall update EMSystem with current hospital/ed status, and keep updated as status /resources change (at least every hour). ii. ED staff or the House Supervisor shall contact neighboring hospitals to assess levels of saturation and communicate the current hospital status. iii. ED staff shall notify the Control Facility of current status. iv. Nurse Administrator shall notify the Administrator on-call of the Level II Activation. h. Communicate Resource Needs i. The Incident Commander (or designee) shall work in collaboration with the MHOAC (or PH DOC if activated) to ensure that adequate resource needs are being assessed on an ongoing basis and necessary resources acquired to address the needs. 3. LEVEL III SURGE (regional): a. Triggers Section I: Page 24 of 35

33 PLACER COUNTY SURGE / ACS PLAN i. Determination by the Incident Commander that the hospital has reached maximum surge levels and is unable to meet the medical needs of the public without intervention or mitigation of regional or state resources. ii. Facility has exceeded both its licensed bed capacity and its surge bed capacity. b. Activation i. Only the Public Health Officer or designee is authorized to activate Level III Surge. ii. The HCC shall be fully activated. iii. Hospital may be required to send an Incident Management Team to the County to plan for the activation of external Alternative Care Sites within Sacramento County. c. Incident Management Team Requirements i. Incident Commander (Administrator) ii. Medical Branch Leader (Patient Care Services Director or designee) iii. Infrastructure Branch Leader (Facility Director or designee) iv. Logistics Branch Leader (Materials Management Manager or designee) v. Security Branch Leader (Security) d. Determine Size and Scope i. The Incident Commander shall complete a high level assessment of the potential operational impact on the facility. e. Internal Alert i. The Incident Commander or designee shall contact the Switchboard Operator, providing any pertinent information about the announcement to be made. ii. Switchboard Operator will announce THREE TIMES over the public address system: (Note: If a Drill, please identify as a Drill. ) ATTENTION PLEASE. CODE TRIAGE: LEVEL III. iii. Switchboard Operator will contact other departments which do not have overhead paging available see list located in area. iv. Switchboard Operator will contact associated clinics, if open, informing them of the Level III Surge. f. Staffing i. Implement staffing ratio increase up to 10:1 in order to meet the needs of the patient population. g. Bed Capacity i. Deployment of Surge Tent (alternate triage point, families, etc.) ii. Consider Establishing External Triage Section I: Page 25 of 35

34 PLACER COUNTY SURGE / ACS PLAN iii. Consider redirecting Minor patients to outpatient sites (e.g. clinics, surge tents, alternate care sites). h. Communicate ED/Hospital Status i. ED staff shall update EMSystem with current hospital/ed status, and keep updated as status /resources change (at least every hour or as directed by the Control Facility). i. Communicate Resource Needs i. The Incident Commander (or designee) shall work in collaboration with the PH DOCMHOAC to ensure that adequate resource needs are being assessed on an ongoing basis and necessary resources acquired to address the needs. j. Participate in Operational Area/Regional Planning Sessions. i. Coordinate any public information with the county EOC and PH DOCMHOAC. ii. Consider implementing disaster hotline for the public (e.g. triage, nurse call line). 4. LEVEL IV SURGE (REGION/STATE): a. Triggers i. Determination by the HCC and PHDOC that implementation of Austere Alternate Medical Protocols is needed in order to provide the most good to the most people in need of medical care resources. b. Activation i. Only the Public Health Officer or designee is authorized to activate Level IV Surge. ii. The HCC shall be fully activated. c. Determine Size and Scope i. The Incident Commander shall complete a high level assessment of the potential operational impact on the facility. d. Internal Alert i. The Incident Commander or designee shall contact the Switchboard Operator, providing any pertinent information about the announcement to be made. ii. Switchboard Operator will announce THREE TIMES over the public address system: (Note: If a Drill, please identify as a Drill. ) ATTENTION PLEASE. CODE TRIAGE: LEVEL IV. iii. Switchboard Operator will contact other departments which do not have overhead paging available see list located in area. iv. Switchboard Operator will contact associate clinics, if open, informing them of the Level IV Surge. e. Staffing Section I: Page 26 of 35

35 PLACER COUNTY SURGE / ACS PLAN i. Implement staffing ratio increase in appropriate areas to meet the needs of the increased patient population. f. Bed Capacity i. Coordinate/prioritize inpatient care with all inpatient care sites ii. Re-assign inpatient areas according to patient needs (e.g. expanded isolation unit, expanded ICU, surgical care unit, etc.) iii. Implement re-assessment, transfer, or discharge of patients according to AustereAlternate Medical protocols approved by the HCC. g. Communicate ED/Hospital Status i. ED staff shall update EMSystem with current hospital/ed status, and keep updated as status /resources change (at least every shift). h. Communicate Resource Needs i. The Incident Commander (or designee) shall work in collaboration with the PH DOC to ensure that adequate resource needs are being assessed on an ongoing basis and necessary resources acquired to address the needs. i. Participate in Operational Area/regional/statewide Planning Sessions Section I: Page 27 of 35

36 PLACER COUNTY SURGE / ACS PLAN A. Planning Factors for determining Alternative Patient Care Sites: 1. Alternative Patient Care Site is a designated location within the hospital for providing inpatient and triage medical care services that would not normally be used for such services. Examples would be visitor waiting areas, hallways, conference room, or an outpatient medical office building. 2. Review the Infection Control Manual for Patient Care risk reduction and exposure control considerations and protocols. a. Do we have or can we provide: i. Temperature and ventilation exhaust control to the space? ii. iii. Access Control/Security? Electrical power? iv. Emergency back-up Power? v. Patient care process flow that allows accessible supervision and services? vi. vii. viii. Waste disposal? Sprinkled building (Fire Suppression System)? Same level Emergency Egress with access widths not less than 45 inches? ix. Personal Hygiene Capabilities (hand washing, changing, and bathroom resources)? x. Communications-telephonic and or overhead capabilities. b. Evacuation: Since a 24 hour stay would be expected for inpatient, we need to ensure the evacuation of patients could occur during a fire related event, therefore should consider evacuation impacts when setting up Alternative Care Sites on multi level floors. c. Storage of Flammable liquids and ignitions sources would need to be assessed and controlled to reduce fire potential in non Hospital Building Occupancy Classifications. d. Space Configuration: Purpose Item description Quantity Type of item 1. 3 Feet of distance aisle way between Patients to reduce spread of infectious diseases. 36 inches between beds. NA Privacy Curtain 2. Access Space for equipment or staff. 24 inches NA Run plugs away from walking paths if possible. 3. Minimum support items. 1. Privacy curtains 2. Waste container 3. Medical Waste container 4. Bed pan/urinals 5. Y Connectors for Oxygen and Suction 4. O2 services. Yes TBD Sharps rated. Portable 5. Power needs. Electrical Surge Strip with a 1 ea Extension cord to connect Section I: Page 28 of 35

37 PLACER COUNTY SURGE / ACS PLAN five plug outlet. 6. Nurse Call system. Manual system (bell) 1 ea 7. Hand Sanitation. Disinfection for staff. For infectious patients. 1 each mounted to bed. surge strip outlet. Manual dispensing. 8. Respiratory Protection for staff. Designate storage. As needed. N95 or PAPR for infectious patients. Section I: Page 29 of 35

38 PLACER COUNTY SURGE / ACS PLAN B. Surge Configuration for Inpatient and Triage Care: (SAMPLE: Kaiser Roseville) Surge Configuration Table for Inpatient Care: Surge Set-Up Time Location 24 hours ROS HOSP ICU Three beds will be added in hallways of suite, or by doubling up rooms. *24 hours ROS HOSP 1 st Floor MED Surge beds can be added to larger rooms beds can be added to main hallway on both wings (south and north). Beds would be on side utilizing electrical outlets. *24 hours ROS HOSP 2 nd Floor MED Surge beds can be added to larger rooms beds can be added to main hallway on both wings (south and north). Beds would be on side utilizing electrical outlets. *24 hours ROS HOSP 3rd Floor MED Surge (Double up rooms and use hall way space). 7 Days ROS HOSP OR (4 4 per room) 2 reserved for Surgeries, and 2 for recovery. > Capacity for Surge Type of Services 23 Inpatient 87 Inpatient 87 Inpatient 80 Inpatient 16 Inpatient 7 Days ROS HOSP PACU 28 Inpatient 7 days ROS EUR MOB 2 nd floor GI 7 Inpatient Total 328 Inpatient NOTE: 1. Surge Availability Timeline: Emergency Triage and Inpatient Surge Planning with an asterisk in the table above requires the facility to maintain within its operational control (Roseville Service Area) the necessary equipment and resources to execute our surge plan without relying on outside support Beds/Gurneys would be needed to support 100% surge for Emergency Triage and Inpatient. We currently have an estimated 299 bed/gurneys at the Medical Center (3/13/07) Military style cots are available in the Emergency Supply Storage Container in ED Parking lot. Section I: Page 30 of 35

39 PLACER COUNTY SURGE / ACS PLAN Surge Set-Up Time Surge Configuration Table for Triage Care: (SAMPLE: Kaiser Roseville) Location Emergency Department > Capacity for Surge Type of Services 0-8 hours Rooms 1 and 2 6 Triage 0-8 hours Rooms 3,4, and 5 4 Triage 0-8 hours Rooms 6,7, and 8 5 Triage 0-8 hours Rooms 9, 10, and 11 5 Triage 0-8 hours Room 12 2 Triage 0-8 hours Room 13 Negative Pressure 2 Triage 0-8 hours Rooms 14 & 15 4 Triage 0-8 hours Room 16 (Eye room) 1 Triage 0-8 hours Room 17 1 Triage 0-8 hours Rooms 18, 19 and 20 6 Triage 0-8 hours Rooms A, B, C, D 4 Triage 0-8 hours Hallway in suite 8 Triage hours Waiting Room 10 Triage hours Hallway next to X-Ray 4 Triage Total 62 Triage NOTE: 1. Surge Availability Timeline: Emergency Triage and Inpatient Surge Planning with an asterisk in the table above requires the facility to maintain within its operational control (Roseville Service Area) the necessary equipment and resources to execute our surge plan without relying on outside support. 2. A receiving and waiting area would need to be relocated outside of ED. Consider setting up the portable tent to support this task. Section I: Page 31 of 35

40 PLACER COUNTY SURGE / ACS PLAN Appendix Section Topic Patient DECON Capacity (HAZMAT) Planning DHS L&C Temporary Permission for Increased Patient Accommodations Request Form Medical Health Operational Area Coordinator (MHOAC) Request Order Form Placer Healthcare MOU Hospital Emergency Supply Inventory Hospital Emergency Room Surge Floor Plans Hospital Inpatient Care Surge Floor Plans TBD TBD TBD TBD TBD TBD TBD Tab Section Section I: Page 32 of 35

41 PLACER COUNTY SURGE / ACS PLAN C. Patient DECON Capacity: (SAMPLE: Kaiser Roseville) The facility has the following patient DECON capabilities to support the community. 1. Mass Casualty Incidents (Six or more patients). a. Quick-E 2 Line Hospital DECON System. The 2 line Decontamination Shelter is for effective decontamination of mass casualties. The system provides shelter for two lines of four stations. i. Station one allow privacy for patients to de-cloth. ii. The next two stations provide rinse decontamination capabilities iii. The last station continues to provide privacy for patients who are provided with temporary clothing. b. Storage Location: All Patient DECON Equipment is stored in the ED Parking lot housed in the Portable Storage Trailer. i. Engineering, Security, and EHS has key access to the equipment. c. Support requirements: i. Water-is the primary resource requirement to provide DECON capability. ii. Portable heater, HAZMAT protective equipment, portable generator, secondary sumps and pumps, and other miscellaneous items are also housed in the Portable Storage Trailer, and the Emergency Supply Conex Container adjacent to Portable Trailer. d. Set-Up expectations: i. Engineering and HAZMAT Team members are responsible for setting up this equipment to support ED s patient care services. ii. HAZMAT Team members will also provide patient DECON support, thus requiring them to suit-up in protective gear which includes the Breathe Easy FR 57 Hood system. iii. Time: It could take approximately minutes to properly assemble the Mass Casualty 2 line Hospital DECON system when staff PPE to include respiratory protection is required. e. Rate of DECON: i. With both lines operational, and adequate staff to support operations, this system could process the following Ambulatory Patients based on two lines operational: Time factors to consider Station one-removing clothing (2 minute step). Station four-clothing patient (2 minute step). Total 4 minutes One minute minimum rinse/patient Total process per hour 60 minutes / (4 min + 1 min) = patients x 2 lines = 24 patients 15 minute shower rinse/patient Total process per hour 60 minutes / (4 min + 15 min) = 3.2 patients x 2 lines= 6.4 patients 2. Small Casualty system (<six patients): Section I: Page 33 of 35

42 PLACER COUNTY SURGE / ACS PLAN a. Single Stall DECON Shower: This system consist of a simple PVC assembled shower over a collection sump that provides continues rinse for single person use b. Storage Location: Stored in the ED Parking lot housed in the Portable Storage Trailer. c. Support requirements: Water-is the primary resource requirement and electricity to operate sump pump to remove contaminated water. d. Set-Up expectations: Engineering and HAZMAT Team members are responsible for setting up this equipment to support ED s patient care services. e. Time: It could take approximately minutes to set-up system. Section I: Page 34 of 35

43 PLACER COUNTY SURGE / ACS PLAN DHS L&C Temporary Permission for Increased Patient Accommodations Request Worksheet (revised 9/27/07) District office: Date: Facility Name: Address: Phone Facility Contact Brief description of Problem: Increased Patient Accommodations requested: Facts to Consider For Increased Patient Accommodation Request: Reschedule non-emergent surgeries and diagnostic procedures. Transfer patients to other beds or discharge as appropriate. Set up clinics for non-emergency cases. (If possible) Request ambulance diversion from LEMSA. LEMSA area of operation is impacted i.e. Multiple hospitals on diversion due to hospital overcrowding. Other Permission Granted: No Yes From: To: L&C Staff Sign Comments / Conditions: Instructions Permission to increase patient accommodations will be granted only in justified emergencies per CCR T (a). Permission will be time limited for a period of time to be determined for each request, depending of the facts presented. Initial approvals are given verbally, and then a signed written approval will be faxed to the facility and the L&C disaster preparedness coordinator (916) A copy of the approval should be filed in the facility folder. This worksheet is an optional form, but the L&C district office, when reviewing these requests, should consider the facts identified above, and all other information deemed relevant by the hospital or the Department under the specific circumstances. Section I: Page 35 of 35

44 PLACER COUNTY SURGE / ACS PLAN Section I: Page 36 of 35

45 Alternate Care Site Plan Activation SECTION 2: ACTIVATION Section II: Page 1 of 10

46 A. Definitions 1. Healthcare Surge Event means an event proclaimed by the Pubic Health Officer or designee, subsequent to a significant event or circumstances, that the healthcare delivery system has been impacted, resulting in an excess in demand over capacity and/or capability in hospitals, community care clinics, public health departments, other primary and secondary care providers, resources, and/or emergency medical services. 2. Standard of Care during a Healthcare Surge means: a. The degree of skill, diligence and reasonable exercise of judgment in furtherance of optimizing population outcome during a healthcare surge event that a reasonably prudent person or entity with comparable training experience or capacity would have used under the circumstances. b. A shift to providing care and allocating scarce equipment, supplies, and personnel in a way that saves the largest number of lives in contrast to the traditional focus on saving individuals. B. Authority California Health and Safety Code, Division 2.5, Sections , California Health and Safety Code, Division 2.5, Section C. Liability 1. Government Code 8659: Any physician or surgeon (whether licensed in this state or any other state), hospital, pharmacist, nurse, or dentist who renders services during any state of war emergency, a state of emergency, or a local emergency at the express or implied request of any responsible state or local official or agency shall have no liability for any injury sustained by any person by reason of such services, regardless of how or under what circumstances or by what cause such injuries are sustained; provided, however, that the immunity herein granted shall not apply in the event of a willful act or omission. 2. Civil Code, : There shall be no liability on the county, city or any other political subdivision of the State of California, who owns or maintains any building or premises which have been designated or are used as mass care centers, first aid stations, temporary hospital annexes, or as other necessary facilities for mitigating the effects of a natural, manmade, or war- Section II: Page 2 of 10

47 caused emergency, for any injuries arising out of the use thereof for such purposes sustained by any person while in or upon said building or premises as a result of the condition of said building or premises or as a result of any act or omission, except a willful act 3. The Emergency Services Act (ESA) authorizes the Governor during a state of emergency to suspend any regulatory statute, or statute prescribing the procedure for conduct of state business, or the orders, rules, or regulations of any state agency, where the Governor determines and declares that strict compliance would in any way prevent, hinder, or delay the mitigation of the effects of the emergency. The authority to suspend statutes is unique to the Governor. Local governing bodies and officials acting under a proclaimed local emergency do not have this power. D. Policy 1. Triggers Consideration should be given to outside resources such as the California Mobile Field Hospital program, California Disaster Medical Assistance Teams (Cal-MATs), and Federal Disaster Medical Assistance Teams (DMATs) while considering the need to establish alternate treatment sites. a. Supportive Care / Medical Shelter This type of ACS shall be activated when it is determined by the Health Officer or designee that: i. Supportive Care / Medical Shelter services are needed within the county, and adequate resources are available for activation; or ii. Adequate resources are unavailable to activate an Inpatient Care ACS, but adequate resources are available for Supportive Care / Medical Shelter ACS b. Outpatient Care This type of ACS shall be activated when it is determined by the Health Officer or designee that: i. Additional Outpatient Care services are needed within the county, and adequate resources are available for activation c. Inpatient Care This type of ACS shall be activated when it is determined by the Health Officer or designee that: i. Additional Inpatient Care services are needed within the county, and adequate resources are available for activation; or ii. Adequate resources are unavailable to activate a Critical Care ACS, but adequate resources are available for an Section II: Page 3 of 10

48 Inpatient Care ACS d. Critical Care / Mobile Field Hospital This type of ACS shall be activated when it is determined by the Health Officer or designee that: i. Additional Critical Care services are needed within the county, and adequate resources are available for activation. 2. Standard of Care a. The Adjusted or Altered Standard of Care during a healthcare surge will be the Standard of Care available and shall be termed "Standard of Care during a Healthcare Surge." b. Triage efforts shall focus on maximizing the number of lives saved. Instead of treating the sickest or the most injured first, triage shall focus on identifying and reserving immediate treatment for individuals who have a critical need for treatment and are likely to survive. 3. Organization Structure a. The ACS Management Team shall report to the Medical/Health Branch Director of the Placer County EOC. b. The ACS Management Team for each ACS shall be comprised of at least the following hospital representatives (additional HICS positions may be required based on needs): i. One clinical care representative (Medical Branch) ii. One finance or resources representative (Logistics) iii. One security representative (Security Branch) iv. One facilities representative (Infrastructure Branch) v. One emergency services representative with a minimum of ICS 300 training (ACS Management Team Leader) c. The ACS shall utilize the Hospital Incident Command System (HICS) organization structure, Job Action Sheets, and Forms modified for use in the ACS. 4. Action Plan a. The ACS Management Team shall develop an Incident Action Plan (IAP) that includes at a minimum: i. Objectives for the current Operational Period (HICS 202) ii. Organizational Assignments (HICS 203) iii. Branch Assignments (HICS 204) Section II: Page 4 of 10

49 iv. Communications Plan (HICS 205) v. Organizational Chart (HICS 207) b. The ACS Action Plan shall be approved by the Medical/Health Branch Director of the Placer County EOC prior to activation. 5. ACS Closure a. The Health Officer or designee and ACS management team members will use professional judgment to determine when to shut down an ACS and oversee shut-down activities in their area of focus. b. Once all patients can be discharged or transported back to existing facilities for continued care and there is no ongoing surge capacity need, the alternate care site shall be closed. c. Shutdown shall be expedited so that the facility can be returned to the control of the existing owners quickly. 6. Medical Record / Documentation a. The ACS Medical Record shall be used on all patients receiving care at the ACS. b. Patient charges shall be recorded on the Patient Charge Capture form (Appendix H). c. Options regarding storage of documents include: i. Public health officer retains all records; ii. Treating facility or provider retains copies of all records; iii. Incident command center retains all records; iv. Patient retains all records. d. In cases where the demand for medical care is high, the most viable option for records retention may be to simply provide the patient with all records upon discharge. 7. Patient Information (Uses and Disclosures) a. HIPAA provides guidance related to uses and disclosures for disaster relief purposes but makes a qualified requirement that the covered entity obtain the patient's consent whenever possible, or rely on its professional judgment that disclosure is in the individual's best interest. Section II: Page 5 of 10

50 b. According to 45 CFR (b)(4): "A covered entity may use or disclose protected health information to a public or private entity authorized by law or by its charter to assist in disaster relief efforts, for the purpose of coordinating with such entities the uses or disclosures permitted by paragraph (b)(1)(ii) of this section. The requirements in paragraphs (b)(2) and (3) of this section apply to such uses and disclosure to the extent that the covered entity, in the exercise of professional judgment, determines that the requirements do not interfere with the ability to respond to the emergency circumstances." c. In response to Hurricane Katrina the U.S. Office for Civil Rights released a bulletin to provide guidance around HIPAA Privacy and Disclosures in Emergency Situations. The bulletin states the following: "Providers and health plans covered by the HIPAA Privacy Rule can share patient information in all the following ways: i. TREATMENT. Health care providers can share patient information as necessary to provide treatment. Treatment includes: sharing information with other providers (including hospitals and clinics), referring patients for treatment (including linking patients with available providers in areas where the patients have relocated), and coordinating patient care with others (such as emergency relief workers or others that can help in finding patients appropriate health services). Providers can also share patient information to the extent necessary to seek payment for these health care services. ii. NOTIFICATION. Health care providers can share patient information as necessary to identify, locate and notify family members, guardians, or anyone else responsible for the individual s care of the individual s location, general condition, or death. The health care provider should get verbal permission from individuals, when possible; but, if the individual is incapacitated or not available, providers may share information for these purposes if, in their professional judgment, doing so is in the patient s best interest. Thus, when necessary, the hospital may notify the police, the press, or the public at large to the extent necessary to help locate, identify or otherwise notify family members and others as to the location and general condition of their loved ones. In addition, when a health care provider is sharing information with disaster relief organizations that, like Section II: Page 6 of 10

51 the American Red Cross, are authorized by law or by their charters to assist in disaster relief efforts, it is unnecessary to obtain a patient s permission to share the information if doing so would interfere with the organization s ability to respond to the emergency. E. Procedure 1. Notifications a. ACS Management Team Once the Public Health Officer or designee has determined the number, type(s), and location(s) of ACS(s) required, the associated ACS Management Team(s) identified in the ACS Management Team Directory shall be activated. 2. Incident Action Plan (IAP) a. Once activated, the ACS management Team shall schedule a planning session within 24 hours for development of an IAP. b. Copies of the completed plan shall be distributed to: i. Control Facility ii. Office of Emergency Services iii. Public Health Department iv. Emergency Medical Services Agency 3. ACS Facility Assessment After developing the IAP, the ACS Management Team shall conduct a Facility Assessment of the target ACS using HICS Form 251 (Appendix C). 4. Equipment & Supply All movement of equipment and supplies shall be tracked, utilizing the HICS Form ACS Closure a. Management team leader checks in periodically with each team member to ensure initiation and completion of shutdown activities in that member's area of focus. b. Management team leader assists with problem troubleshooting or procuring additional assistance or resources as needed. c. Management team leader or designee conducts a site walkthrough with the facility owner when shutdown activities are completed to ensure that removal of equipment and supplies, cleaning, and other Section II: Page 7 of 10

52 surge closure activities have been completed to the owner's satisfaction. d. Perform medical record documentation storage procedures. F. Attachments: 1. ACS Management Team Directory. Page 9 2. ACS Patient Charge Capture...Appendix H 3. ACS Medical Record. Appendix I Section II: Page 8 of 10

53 ACS MANAGEMENT TEAM DIRECTORY Position Facility Name Phone Cell/Other Sutter Roseville Team Leader Kaiser Roseville Sutter Auburn Faith Clinical Care Sutter Roseville Kaiser Roseville Sutter Auburn Faith Facilities Finance / Supply Security Section II: Page 9 of 10

54

55 ACS PATIENT RECORD Section II: Page 10 of 10

56

57 Alternate Care Site Staffing Plan SECTION 3: STAFFING Section III: Page 1 of 8

58 A. Purpose The purpose of the ACS Staffing Plan is to outline a process for identifying and obtaining initial staff and maintaining adequate staffing levels for the operation of an Alternate Care Site, as well as to ensure proper support, protections, and training to staff and volunteers. B. Policy 1. ACS HICS Structure a. The ACS shall utilize the modified Hospital Incident Command System (HICS) organization structure and Job Action Sheets. b. The ACS Management Team shall appoint a Medical Care Branch Director, Infrastructure Branch Director, and Security Services Branch Director to assist in identifying needed personnel and resources to effectively operate the ACS. c. The ACS Management Team shall appoint a Labor Pool & Credentialing Unit Leader to obtain and inventory available staff. 2. Staffing Requests a. The ACS Management Team, in cooperation with the MHOAC, shall determine the appropriate sources for obtaining needed personnel. Consider utilizing the following: i. Shared Resources from Local Health Facilities ii. Temporary Staffing Agencies iii. Statewide Medical/Health Mutual-aid System (MHOAC) (Cal-MAT, DMAT, National Guard, Mobile Hospitals) iv. California Medical Volunteer database v. Health Professional Schools vi. Recruitment of local medical personnel/volunteers b. The Labor Pool & Credentialing Unit Leader shall determine the number and type of personnel needed, utilizing the Matrix for ACS Estimated Staffing Levels 3. Emergency Credentialing of Medical Staff a. The Labor Pool & Credentialing Unit Leader shall utilize facilityspecific protocols to document all emergency credentialing activities. b. Licensed independent practitioners (such as physicians, advanced practice nurses, and registered nurses) who request temporary disaster privileges during a period of officially declared emergency must be currently licensed. c. Identification requirements for those practitioners requesting disaster privileging, include at a minimum: Section III: Page 2 of 8

59 i. identification should include a valid government-issued photo identification issued by a state or federal agency (e.g., driver s license or passport) and at least one of the following: A current picture hospital identification card. A current license to practice and a valid picture identification issued by a state, federal, or regulatory agency. Identification indicating that the individual is a member of the California Medical Assistance Team (CalMAT) or of a Disaster Medical Assistance Team (DMAT). Documentation indicating that the individual has been granted authority to render patient care in disaster circumstances, such authority having been granted by a federal, state, or municipal entity. Presentation by current hospital or medical staff member(s) with personal knowledge regarding the practitioner's identity. d. Following disaster credentialing, the practitioner shall be provided and maintained on his or her person written verification of said privileges. The medical staff bylaws, rules and regulations require that his or her notations in the medical record reflect that the practitioner is working under disaster privileges. e. For quality review purposes, a list of all patient encounters shall be kept, if practical. f. Allied Health Professionals (AHP) shall be similarly considered for temporary privileges, and shall be subject to the same general conditions of supervision except that supervision may be performed by an AHP with current like privileges. g. Emergency temporary privileges may be rescinded at any time, and there shall be no rights to any hearing or review, regardless of the reason for such termination. h. Temporary disaster privileges are terminated at the end of the declared disaster. 4. Medical Staff Bylaws In case of an emergency, any member of the medical staff, house staff, and any licensed health practitioner, limited only by the qualifications of their license and regardless of service or staff status, shall be permitted to render emergency care. Any Licensed Health Practitioner acting in an emergency or disaster situation shall be exempt from the usual requirements of supervision to the extent allowed by state law in disaster or emergency situations. 5. Maintaining Personnel a. Safeguarding Personnel Health and Safety The Labor Pool Unit Leader shall ensure that all workforce Section III: Page 3 of 8

60 personnel are informed of any potential hazards and provided with any necessary personal protective equipment (PPE) or vaccinations as may be required by the event. b. Providing Support Provisions i. The ACS Management Team shall consider the need to appoint a Support Branch Director or Family Care Unit Leader to enhance the ability to recruit staff that may require childcare or dependent care. ii. The Support Branch Director or Family Care Unit Leader shall consider and make provision for: Behavioral Health needs of staff Dependent Care (children/adults) needs of staff (coordinate with the Child Care Center Coordinator at the Placer County Office of Education) Pet Care needs of staff Personal Hygiene and rest area needs of staff 6. Scope of Practice and Professional Liability a. Waivers of Current Standards i. Government Code 8659, under the California Emergency Services Act states that any physician or surgeon (whether licensed in this state or any other state), hospital, pharmacist, nurse, or dentist who renders services during any state of war emergency, a state of emergency, or local emergency at the express or implied request of any responsible state or local official or agency shall have no liability for any injury sustained by any person by reason of such services, regardless of how or under what circumstances or by what cause such injuries are sustained; provided, however, that the immunity herein granted shall not apply in the event of a wilful act or omission. ii. The Good Samaritan Statutes under Business & Professions Codes 2395, , 2396 and 2398 state that no licensee, who in good faith renders emergency care at the scene of an emergency, shall be liable for any civil damages as a result of any acts or omissions by such person in rendering the emergency care. The scene of an emergency as used in this section shall include, but not be limited to, the emergency rooms of hospitals in the event of a medical disaster. Medical disaster means a duly proclaimed state of emergency or local emergency declared pursuant to California Emergency Services act. b. Scope of Practice/ Non-traditional Roles The Licensing Boards of each of licensed practitioners shall be contacted to determine if flexibility currently exists within their scope Section III: Page 4 of 8

61 C. Procedure of practice or may be drafted for approval. c. Financial Liability Financial liability: The recipient healthcare facility will likely reimburse the donor healthcare facility for the salaries and benefits of the donated personnel at the donated personnel's rate as established at the donor healthcare facility if the personnel are employees being paid by the donor healthcare facility. The reimbursement will be made within ninety days following receipt of the invoice. 1. Assessment of Workforce Need a. The Labor Pool Unit Leader shall utilize the Matrix for ACS Estimated Staffing Levels to determined levels and numbers of clinical staff needed. b. The Labor Pool Unit Leader shall utilize the Matrix for ACS Estimated Staffing Levels to determined levels and numbers of non-clinical staff needed. 2. Augmenting the Workforce (utilizing SEMS) a. The Labor Pool & Credentialing Unit Leader shall complete the Mission/Request Tasking Form and submit requests for personnel to local healthcare provider agencies, to include: i. The type and number of requested personnel. ii. An estimate of how quickly the request is needed. iii. The location to where personnel are to report. iv. An estimate of how long the personnel will be needed. 3. Receiving and Organizing Personnel a. Sign-in The Labor Pool Unit Leader or designee shall conduct sign-in for all clinical and non-clinical personnel, utilizing the HICS Form Section Personnel Time Sheet. b. Credentialing and Verification The Labor Pool Unit Leader or designee shall ensure that an application for each practitioner shall be completed and maintained on file at the facility, and shall: i. conduct a primary source verification of licensure (if applicable) as soon as the immediate situation is under control and is completed within 72 hours from the time the non-employee or volunteer presents to the organization. ii. determine the duties and area of assignment of those with emergency privileges. Section III: Page 5 of 8

62 iii. distribute temporary I.D. badges that are clearly labeled as a Disaster Volunteer to all emergency credentialed personnel. c. Orientation The Labor Pool Unit Leader or designee, in cooperation with the Medical Care Branch Director, Infrastructure Branch Director, and Security Services Branch Director, shall ensure that incident-specific materials are prepared for clinical and non-clinical personnel, including: i. Training for All Workers ii. Department-specific Training iii. Training for Ad hoc Counselors iv. Information Packets for Handouts v. Assignment of Job Duty 4. Incident Command Structure The ACS shall institute an ACS incident command structure adapted from the existing Hospital Incident Command System (HICS) for the internal operations including, at a minimum,: a. Incident Commander. The incident commander assumes overall leadership. He/she is assisted by several advisors/coordinators who deal with the news media, other agencies, security and safety, and physician assignment. The four major section chiefs are assigned by the incident commander. Each chief designates directors and unit leaders to sub-functions. b. Logistics Section Chief. The logistics section chief focuses on operations associated with the physical environment and ensuring adequate levels of food, shelter and supplies. He/she is responsible for power; utilities; sanitation; water; trash; communication systems (telephone, intercom, paging system); transportation of supplies, patients, and staff; and meals for patients and staff. c. Planning Section Chief. The planning section is responsible for compiling information about the current situation and developing long-range planning. He/she is to keep staff up to date regarding the current disaster situation inside the hospital and in the surrounding area, maintain an inventory of available staff and volunteers, organize and coordinate medical and nursing staff, track patient census by location and status, and anticipate needs. d. Finance Section Chief. The finance section is to monitor the utilization of financial assets. He/she is responsible for Section III: Page 6 of 8

63 the accounting and documentation of all resource expenditures, providing cost analysis data, maintaining personnel time records, negotiating and/or issuing contracts to purchase or obtain resources and receiving and investigating all accident/incident claims resulting from an employee action on hospital property. e. Operations Section Chief. This is a large section covering the overall delivery of medical care, ancillary services, and staff support. This group is responsible for triage; patient admissions and discharges; planning for short- and longterm staffing and medical resource needs; morgue services; overseeing laboratory, radiology, and pharmacy services; and the social and psychological needs of the staff, patients, and families. This group would also be responsible for sheltering and feeding of staff and volunteer dependents. 5. Demobilization of Personnel The Planning Section Chief or Demobilization Unit Leader shall develop and coordinate an Incident Demobilization Plan that includes specific instructions for all staff and resources that will require demobilization. Attachments: 1. Matrix for ACS Estimated Staffing Levels.. Page 8 2. Mission/Request Tasking Form Appendix F 3. HICS Form Section Personnel Time Sheet. Appendix C Section III: Page 7 of 8

64 Estimated Staffing Levels for Surge The following table is presented as a recommendation for staffing levels for an Alternate Care Site of 50 patients. Staff Type Staff Inpatient Outpatient Supportive Medical Director Physician Internist (on-call) Nursing Allied Health Food Service Environmental Services Security Nursing Director Supervisor RN/LVN/CNA Dietician Discharge Planner Phlebotomist Respiratory Therapist Food Service Supervisor Cook Food Service Worker Maintenance Laundry Housekeeping Security Personnel day shift 5 night shift 5 day shift 2 night shift Section III: Page 8 of 8

65 Alternate Care Site Supply Plan SECTION 4: SUPPLY Section IV: Page 1 of 4

66 A. Purpose The purpose of this policy is to establish procedures to support the medical/health care at an Alternate Care Site. B. Policy 1. ACS HICS Structure a. The ACS shall utilize the modified Hospital Incident Command System (HICS) organization structure and Job Action Sheets. b. The ACS Management Team shall appoint an ACS Supply Unit Leader and Food Services Unit Leader to assist in developing a plan to supply needed resources to effectively operate the ACS for at least 96 hours. 2. Assessment of Resources a. The ACS Management Team, in cooperation with the MHOAC, shall determine the appropriate sources for obtaining needed equipment and supplies. Consider utilizing the following: i. Local Resource Caches ii. Resources from Local Health Facilities (MOU) iii. Regional/State/Federal Caches iv. Local Vendors v. Medical / Health Mutual-Aid System b. The ACS Supply Unit Leader shall determine the number and type of resources needed, utilizing the ACS Equipment/Supply Matrix. 3. Inventory Management a. The MHOAC shall develop and maintain the Placer County Medical/Health Equipment & Supply Inventory, which shall be annually updated. b. The ACS inventory shall be managed so the supplies can be effective when used. Therefore, there shall be a process to monitor expiration dates, storage dates, and a process for rotating stock from a cache into the general inventory to minimize supplies that may expire. c. All movement of equipment and supplies shall be tracked, utilizing the HICS Form Board of Pharmacy Waiver a. In the event of a declared disaster or emergency, the California Board of Pharmacy expects to utilize its authority under the California Business and Professions Code, including section 4062, subdivision (b) thereof, to encourage and permit emergency provision of care to affected patients and areas, including by waiver Section IV: Page 2 of 4

67 of requirements that it may be implausible to meet under these circumstances, such as prescription requirements, record-keeping requirements, labeling requirements, employee ratio requirements, consultation requirements, or other standard pharmacy practices and duties that may interfere with the most efficient response to those affected. b. The board encourages its licensees to assist, and follow directions from, local, state, and national health officials. The board expects licensees to apply their judgment and training to providing medication to patients in the best interests of the patients, with circumstances on the ground dictating the extent to which regulatory requirements can be met in affected areas. The board further expects that during such emergency, the highest standard of care possible will be provided, and that once the emergency has dissipated, its licensees will return to practices conforming to state and federal requirements. C. Procedure 1. Resource Requests a. The ACS Supply Unit Leader and Food Services Unit Leader shall determine the available inventory of the following, based on the type of event (see Equipment/Supply Matrix). This may include, but is not limited to: i. IV Fluids ii. Bandages and Wound Management iii. Airway Intervention and Management iv. Immobilization v. Patient Bedding, Gowns, Cots, Misc. vi. Healthcare Provider Personal Protective Equipment (PPE) vii. Exam Supplies viii. General Supplies ix. Defibrillators and Associated Supplies b. Complete a status report and a formal request for assistance, utilizing the Medical Resource Request Form. c. This formal request should be submitted to the MHOAC and should be specific and quantifiable. d. Ensure that when acknowledgement of the request is received, it is saved and used to track request status. The acknowledgement should contain: i. Confirmation of the specific request that was made. ii. The anticipated response time. iii. Any additional information on the scope and impact of the disaster and its effect on mutual aid requests. Section IV: Page 3 of 4

68 e. Prepare to reconfirm a response time of request if the request is not fulfilled as anticipated. 2. Inventory Management a. Establish the process for the rotation of stock and inventory (control management). b. Clarify the process for how materials get delivered. c. Identify where materials will be delivered so there are one or more specific locations that delivery is expected. 3. Resource Tracking a. All movement of equipment and supplies shall be tracked, utilizing the HICS Form 256. b. Closely monitor equipment, supply, and pharmaceutical usage. c. Ensure a process for security and control of medications, equipment, and supplies, as needed. 4. Demobilization of Resources Work with the Planning Section Chief or Demobilization Unit Leader to develop and coordinate an Incident Demobilization Plan that includes specific instructions for all resources that will require demobilization. D. Attachments: 1. ACS Equipment Supply Matrix Appendix H 2. Medical Resource Request Form Appendix F 3. HICS Form 256 Resource Tracking.. Appendix C Section IV: Page 4 of 4

69 Alternate Care Site Security Plan SECTION 5: SECURITY Section V: Page 1 of 6

70 A. Background Safety and security is the most essential operational requirement of an ACS. Without proper safety and security measures at an ACS, the lives of patients and personnel will be in jeopardy. It is recommended that an ACS be open to the public ONLY IF at a minimum at least two armed guards are present at the time of opening. Security needs and goals at the ACS may require more security than under normal conditions of operations given the nature of the disaster. These include general safety of patients, staff, and visitors, and protection of pharmaceuticals and other assets. However, typical measures to achieve security would be more complex for an ACS due to the following reasons. 1. Since this is a temporary ACS facility; the facility itself and security procedures will be unfamiliar and not yet routine to the security staff. Therefore, protocols will be more difficult to maintain and unusual events will be more difficult to identify 2. ACS personnel will not be known to security staff or to one another, therefore unauthorized persons will be more difficult to identify 3. Mechanical and electronic security controls would be quickly retrofitted onto the ACS structure and may not be of optimal design and function for this facility 4. All personnel, patients, and visitors will be under heightened stress due to the catastrophic event that necessitated opening of the ACS 5. Protestors and demonstrators (for example, animal rights activists) may target the ACS During an infectious agent or communicable disease epidemic scenario, there are significant additional security concerns and risks beyond those mentioned above. If the ACS is to serve as an isolation/quarantine facility for infectious patients, there could be a strong not-in-my-backyard reaction from the community surrounding the surge facility, generated by fear of the infectious agent. This could cause community members to object and try to prevent the facility from opening and receiving patients, and might lead to disruption of facility operations. If there is widespread perceived risk from the infectious agent, and if vaccinations and medical prevention and treatment are in short supply, there could be aggressive attempts to obtain or steal medications from the surge facility. These are serious and real security risks, and they will be difficult to manage under the conditions of a quickly opened temporary surge facility. The following additional measures should be considered: 1. Providing security for incoming and outgoing vehicles (for roadways between site perimeter and major corridors through the community), in particular those transporting infected patients. 2. Controlling access to the grounds. 3. Heightened access control into and around the building. 4. More stringent identification and tracking of patients, staff, and visitors. B. Purpose Section V: Page 2 of 6

71 To establish a process for coordination all of the activities related to personnel and facility security such as access control, crowd and traffic control, and law enforcement interface. C. Policy 1. Appointment a. The ACS Management Team shall appoint a Security Branch Director under the HICS organization structure for this facility. D. Procedure 1. Security Plan a. The Security Branch Director shall develop a Security Plan with key objectives for security personnel using the HICS Branch Assignment Form 204. b. Consider site-specific needs, including: i. Security protocols to be followed and exact parameters of responsibility. ii. Chain of command guidance. iii. Patrol of parking and shipping areas for suspicious activity iv. Traffic Control v. Removing unauthorized persons from restricted areas vi. Need for security personnel to use personal protective equipment 2. Staffing a. The Security Branch Director shall determine number and types of security personnel needed to adequately equip the ACS. Consideration should be given to the following: i. Number of security personnel needed and in what timeframe. (It should be readily feasible to get up to 10 security personnel from a private firm within 24 hours.) ii. Level of training needed. iii. Gear and equipment specifications. iv. Number of personnel who need to be armed. v. An estimate of how long the personnel will be needed. b. Personnel needs shall be reported to the Labor Pool Unit Leader. 3. Receiving and Organizing Personnel a. Sign-in The Security Branch Director shall ensure that all security personnel signin with the Labor Pool Unit Leader upon arrival at the ACS. b. Orientation The Security Branch Director shall ensure that all security personnel are provided with site-specific training, including any necessary PPE and potential hazardous materials. Section V: Page 3 of 6

72 c. Assignment of Job Duty Upon check-in, the Security Branch Director shall provide copies of the Security Branch Assignment Form 204 to security personnel with position-specific objectives. d. Access Control Parameters i. Control of access to the site and the building would be achieved through security personnel, physical barriers such as fencing and mechanical and electronic devices such as locks, card reader systems on doors, and security cameras. There is a strong interplay between these security methods. As an example, if doorways cannot be locked or secured with electronic card readers, additional security staff will be needed at each doorway. ii. The exterior windows, doors, and other structural components of the ACS building should be in place with no breach in the building envelope allowing for building access other than in normal doorway entrances. Locks on doors and windows should be in place and functional. A limited number of building entranceways (approximately a half dozen or fewer) should be established. Exterior doorways should be controlled with locks and if possible electronic card readers. If not, security experts estimate that three to four security personnel would be needed per shift to control building access and monitor the building. If doorways could not be secured via use of such technology, additional security personnel would be needed to control these doorways. iii. ACS(s) should have a lockable pharmacy area. Aside from the lockable doors, there should be security personnel and if possible, alarms and cameras. Installation of some of these additional security controls may be needed to protect the pharmacy area under the isolation/quarantine scenario if there is a general shortage of vaccines or preventive or curative medications as described in the introduction. iv. A security process should be set up for the following: Ensuring the security of existing inventory and caches by utilizing personnel or security cameras. Controlling access into and within the building area. Identifying and tracking patients, staff, and visitors. Working with local authorities prior to a surge to address heightened security Working with private security entities prior to a surge to address heightened security. v. Personnel responsible for access control shall be provided a site diagram indicating the perimeter of ACS operations, as well as authorized entry and exit points for staff, patients, and visitors. Section V: Page 4 of 6

73 e. Communications Plan (HICS 205) The Security Branch Director shall work with the Operations Section Chief to identify the methods of communications for security personnel are outlined in the Communications Plan- Form 205. Copies of the Communications Plan- Form 205 shall be provided to security personnel as necessary. f. Assignment of Equipment i. The Security Branch Director shall determine resource needs and make assignment of security equipment, including Keys, Portable Radios, Placards, Caution Tape, etc. ii. All assignment of equipment shall be documented, using the Resource Account Record Form Demobilization of Personnel The Security Branch Director shall work with the Operations Section Chief to coordinate all demobilization activities of the security personnel. E. Attachments: 1. HICS Branch Assignment Form 204. Appendix C 2. HICS Communications Plan- Form Appendix C 3. HICS Resource Accounting Record- Form 257. Appendix C Section V: Page 5 of 6

74 Section V: Page 6 of 6

75 Alternate Care Site Patient Movement Plan SECTION 6: PT MOVMENT Section VI: Page 1 of 4

76 A. Purpose 1. The purpose of this plan is to ensure orderly and timely movement of patients between licensed medical facilities and Alternate Care Sites. 2. The following related policies will be the basis for conducting patient movement between facilities during a local state of emergency. 3. This plan is intended to augment, and not replace, the OES Region IV MCI Plan for Patient Movement. B. Policy 1. Transferring Patients to an Alternate Care Site a. Care Level Patients identified for transfer to an ACS shall be within the appropriate care level of the ACS (i.e. palliative/supportive care vs. acute care). b. Patient Identification i. All patients approved for transfer to the ACS shall have a countyapproved Triage Tag containing a unique identification number and barcode containing the county s 2-digit prefix (i.e. Placer County prefix 31 + tag number). ii. The patient Triage Tag ID number shall be transcribed to the patient s medical record for tracking purposes. c. Patient Transportation Unit Leader A transferring facility shall appoint a Patient Transportation Unit Leader to coordinate the transfer of patients to an ACS. d. Transportation Resources All requests for medical transportation resources shall be directed to the MHOAC during a declared local emergency. e. Transportation Worksheet i. All patients identified for transfer to an ACS shall be documented by the Patient Transportation Unit Leader on the Patient Transportation Worksheet. ii. All completed Patient Transportation Worksheets shall be faxed to the MHOAC upon request. f. ACS Transfer Summary i. The Patient Transportation Unit Leader shall ensure that a Transfer Summary is completed for each patient requiring transport to an ACS. C. Procedure 1. Patient Movement Section VI: Page 2 of 4

77 a. Once a facility has identified patients for transfer to an ACS, the transferring facility shall: i. Contact the ACS Medical Care Branch Director to accept the transfer. ii. Ensure a county-approved Triage Tag I.D. is assigned to the patient. iii. Complete an ACS Transfer Summary Worksheet for each patient. iv. Appoint a Patient Transportation Unit Leader to coordinate the patient transportation. b. The Patient Transportation Unit Leader shall notify the ACS Medical Care Branch Director when the patient is enroute, and report Patient Name, Transport Unit #, and ETA. c. Upon arrival at the ACS, the Medical Care Branch Director, or designee, shall complete the Receiving Facility portion of the ACS Transfer Summary and ensure the patient information is properly documented on the Disaster Victim / Patient Tracking Log. D. Attachments: 1. Patient Transportation Worksheet Page 4 2. HICS Form 254 Disaster Victim / Patient Tracking Log. Appendix C Section VI: Page 3 of 4

78 Patient Transportation Worksheet Patient Ready Patient Category Mode of Transportation Ambulance Identification Patient Name Triage Tag # Destination Depart Time G W/C A G W/C A G W/C A G W/C A G W/C A G W/C A G W/C A G W/C A G W/C A G W/C A G W/C A G W/C A G W/C A G W/C A G W/C A G W/C A G W/C A G W/C A Section VI: Page 4 of 4

79 PLACER COUNTY SURGE / ACS PLAN APPENDICES A. ACS HICS Organization Chart B. ACS HICS Job Action Sheets C. HICS Forms D. Target ACS Facility Assessments E. SAMPLE MOU for Use of Facilities in the Event of a Mass Medical Emergency F. Medical Resource Request Form G. Placer County Healthcare MOU H. ACS Patient Charge Capture I. ACS Equipment / Supply Matrix SECTION 7: APPENDICES Section VII: Page 1 of 138

80 Section VII: Page 2 of 138

81 ACS ORG CHART APPENDIX A Section VII: Page 3 of 138

82 Section VII: Page 4 of 138

83 ACS / HICS JOB ACTION SHEETS APPENDIX B Section VII: Page 5 of 138

84 Section VII: Page 6 of 138

85 INCIDENT COMMANDER Mission: Organize and direct the Hospital Command Center (HCC). Give overall strategic direction for hospital incident management and support activities, including emergency response and recovery. Authorize total facility evacuation if warranted. Date: Start: End: Position Assigned to: Signature: Initial: Hospital Command Center (HCC) Location: Telephone: Fax: Other Contact Info: Radio Title: Immediate (Operational Period 0-2 Hours) Time Initial Assume role of Incident Commander and activate the Hospital Incident Command System (HICS). Read this entire Job Action Sheet and put on position identification. Notify your usual supervisor and the hospital CEO, or designee, of the incident, activation of HICS and your HICS assignment. Initiate the Incident Briefing Form (HICS Form 201) and include the following information: Nature of the problem (incident type, victim count, injury/illness type, etc.) Safety of staff, patients and visitors Risks to personnel and need for protective equipment Risks to the facility Need for decontamination Estimated duration of incident Need for modifying daily operations HICS team required to manage the incident Need to open up the HCC Overall community response actions being taken Status of local, county, and state Emergency Operations Centers (EOC) Contact hospital operator and initiate hospital s emergency operations plan. Determine need for and appropriately appoint Command Staff and Section Chiefs, or Branch/Unit/Team leaders and Medical/Technical Specialists as needed; distribute corresponding Job Action Sheets and position identification. Assign or complete the Branch Assignment List (HICS Form 204), as appropriate. Brief all appointed staff of the nature of the problem, immediate critical issues and initial plan of action. Designate time for next briefing. Assign one of more clerical personnel from current staffing or make a request for staff to the Labor Pool and Credentialing Unit Leader, if activated, to function as the HCC recorder(s). Distribute the Section Personnel Time Sheet (HICS Form 252) to Command Staff and Medical/Technical Specialist assigned to Command, and ensure time is recorded appropriately. Submit the Section Personnel Time Sheet to the Finance/Administration Section s Time Unit Leader at the completion of a shift or at the end of each operational period. Initiate the Incident Action Plan Safety Analysis (HICS Form 261) to document hazards and define mitigation. Receive status reports from and develop an Incident Action Plan with Section Chiefs and Command Staff to determine appropriate response and recovery levels. During initial briefing/status reports, discover the Section VII: Page 7 of 138

86 Immediate (Operational Period 0-2 Hours) Time Initial following: If applicable, receive initial facility damage survey report from Logistics Section Chief and evaluate the need for evacuation. If applicable, obtain patient census and status from Planning Section Chief, and request a hospital-wide projection report for 4, 8, 12, 24 & 48 hours from time of incident onset. Adjust projections as necessary. Identify the operational period and HCC shift change. If additional beds are needed, authorize a patient prioritization assessment for the purposes of designating appropriate early discharge. Ensure that appropriate contact with outside agencies has been established and facility status and resource information provided through the Liaison Officer. Seek information from Section Chiefs regarding current on-hand resources of medical equipment, supplies, medications, food, and water as indicated by the incident. Review security and facility surge capacity and capability plans as appropriate. Document all key activities, actions, and decisions in an Operational Log (HICS Form 214) on a continual basis. Document all communications (internal and external) on an Incident Message Form (HICS Form 213). Provide a copy of the Incident Message Form to the Documentation Unit. Intermediate (Operational Period 2-12 Hours) Time Initial Authorize resources as needed or requested by Command Staff. Designate regular briefings with Command Staff/Section Chiefs to identify and plan for: Update of current situation/response and status of other area hospitals, emergency management/local emergency operation centers, and public health officials and other community response agencies Deploying a Liaison Officer to local EOC Deploying a PIO to the local Joint Information Center Critical facility and patient care issues Hospital operational support issues Risk communication and situation updates to staff Implementation of hospital surge capacity and capability plans Ensure patient tracking system established and linked with appropriate outside agencies and/or local EOC Family Support Center operations Public information, risk communication and education needs Appropriate use and activation of safety practices and procedures Enhanced staff protection measures as appropriate Public information and education needs Media relations and briefings Staff and family support Development, review, and/or revision of the Incident Action Plan, or elements of the Incident Action Plan Oversee and approve revision of the Incident Action Plan developed by the Planning Section Chief. Ensure that the approved plan is communicated to all Command Staff and Section Chiefs. Communicate facility and incident status and the Incident Action Plan to CEO or designee, or to other executives and/or Board of Directors members on a need-to-know basis. Extended (Operational Period Beyond 12 Hours) Time Initial Section VII: Page 8 of 138

87 Extended (Operational Period Beyond 12 Hours) Time Initial Ensure staff, patient, and media briefings are being conducted regularly. Review and revise the Incident Action Plan Safety Analysis (HICS Form 261) and implement correction or mitigation strategies. Evaluate/re-evaluate need for deploying a Liaison Officer to the local EOC. Evaluate/re-evaluate need for deploying a PIO to the local Joint Information Center. Ensure incident action planning for each operational period and a reporting of the Incident Action Plan at each shift change and briefing. Evaluate overall hospital operational status, and ensure critical issues are addressed. Review /revise the Incident Action Plan with the Planning Section Chief for each operational period. Ensure continued communications with local, regional, and state response coordination centers and other HCCs through the Liaison Officer and others. Ensure your physical readiness, and that of the Command Staff and Section Chiefs, through proper nutrition, water intake, rest periods and relief, and stress management techniques. Observe all staff and volunteers for signs of stress and inappropriate behavior. Report concerns to the Employee Health & Well-Being Unit Leader. Upon shift change, brief your replacement on the status of all ongoing operations, critical issues, relevant incident information and Incident Action Plan for the next operational period. Demobilization/System Recovery Time Initial Assess the plan developed by the Demobilization Unit Leader and approved by the Planning Section Chief for the gradual demobilization of the HCC and emergency operations according to the progression of the incident and facility/hospital status. Demobilize positions in the HCC and return personnel to their normal jobs as appropriate until the incident is resolved and there is a return to normal operations. Briefing staff, administration, and Board of Directors Approve announcement of ALL CLEAR when incident is no longer a critical safety threat or can be managed using normal hospital operations Ensure outside agencies are aware of status change Declare hospital/facility safety Ensure demobilization of the HCC and restocking of supplies, as appropriate including: Return of borrowed equipment to appropriate location Replacement of broken or lost items Cleaning of HCC and facility Restock of HCC supplies and equipment; Environmental clean-up as warranted Ensure that after-action activities are coordinated and completed including: Collection of all HCC documentation by the Planning Section Chief Coordination and submission of response and recovery costs, and reimbursement documentation by the Finance/Administration and Planning Section Chiefs Conduct of staff debriefings to identify accomplishments, response and improvement issues Identify needed revisions to the Emergency Management Plan, Emergency Operations Plan, Job Action Sheets, operational procedures, records, and/or other related items Writing the facility/hospital After Action Report and Improvement Plan Participation in external (community and governmental) meetings and other post-incident discussion Section VII: Page 9 of 138

88 Demobilization/System Recovery Time Initial and after-action activities Post-incident media briefings and facility/hospital status updates Post-incident public education and information Stress management activities and services for staff Documents/Tools Incident Action Plan HICS Form 201 Incident Briefing Form HICS Form 204 Branch Assignment List HICS Form 207 Incident Management Team Chart HICS Form 213 Incident Message Form HICS Form 214 Operational Log HICS Form 252 Section Personnel Time Sheet HICS Form 261 Incident Action Plan Safety Analysis Hospital emergency operations plan and other plans as cited in the JAS Hospital organization chart Hospital telephone directory Radio/satellite phone Section VII: Page 10 of 138

89 PUBLIC INFORMATION OFFICER Mission: Serve as the conduit for information to internal and external stakeholders, including staff, visitors and families, and the news media, as approved by the Incident Commander. Date: Start: End: Position Assigned to: Initials: Position Reports to: Incident Commander Signature : Hospital Command Center (HCC) Location: Telephone: Fax: Other Contact Info: Radio Title: Immediate (Operational Period 0-2 Hours) Time Initial Receive appointment and briefing from the Incident Commander. Read this entire Job Action Sheet and review incident management team chart (HICS Form 207). Put on position identification. Notify your usual supervisor of your HICS assignment. Activate the facility communications and risk communications plan, policies and procedures. Establish a designated media staging and media briefing area located away from the HCC and patient care activity areas. Inform on-site media of the physical areas to which they have access and those which are restricted. Coordinate designation of such areas with the Safety Officer and the Security Branch Director. Contact external Public Information Officers from community and governmental agencies to ascertain and collaborate public information and media messages being developed by those entities to ensure consistent and collaborative messages from all entities. Consider need to deploy PIO to local Joint Information Center, if activated. Develop public information and media messages to be reviewed and approved by the Incident Commander before release to the news media and the public. Identify appropriate spokespersons to deliver the press briefings and public information announcements. Attend all command briefings and incident action planning meetings to gather and share incident and hospital information. Conduct or assign personnel to monitor and report to you incident and response information from sources such as the internet, radio, television and newspapers. Request one or more recorders and other support staff as needed from the Labor Pool & Credentialing Unit Leader, if activated, to perform all necessary activities and documentation. Document all key activities, actions, and decisions in an Operational Log (HICS Form 214) on a continual basis. Document all communications (internal and external) on an Incident Message Form (HICS Form 213). Provide a copy of the Incident Message Form to the Documentation Unit. Intermediate (Operational Period 2-12 Hours) Time Initial Continue to attend all Command briefings and incident action planning meetings to gather and share incident and hospital information. Contribute media and public information activities and goals to the Incident Action Plan. Continue contact and dialogue with external Public Information Officers, in collaboration with the Liaison Officer, from community and governmental agencies to ascertain public information and media messages being Section VII: Page 11 of 138

90 Intermediate (Operational Period 2-12 Hours) Time Initial developed by those entities to ensure consistent and collaborative messages from the hospital/facility. Coordinate translation of critical communications into multiple languages. Determine whether a local, regional or State Joint Information Center (JIC) is activated, provide support as needed, and coordinate information dissemination. Continue to develop and revise public information and media messages to be reviewed and approved by the Incident Commander before release to the news media and the public. Ensure that media briefings are done in collaboration with JIC, when appropriate. Develop regular information and status update messages to keep staff informed of the incident and community and hospital/facility status in collaboration with the Employee Health and Well-Being Unit Leader, the Family Care Unit Leader and the Mental Health Unit Leader. Utilize internal hospital communications systems (e.g., , intranet, internal TV, written report postings, etc.) to disseminate current information and status update messages to staff. Assess the need to activate a staff hotline for recorded information concerning the incident and facility status and establish the hotline if needed. Issue regular and timely incident information reports to the news media in collaboration with of the Situation Unit Leader and Liaison Officer, to be approved by the Incident Commander. Relay pertinent information received to the Situation Unit Leader and the Liaison Officer. Review the need for updates of critical information through in way finding and signage for staff, visitors and media. Assist in the development and dissemination of signage. Coordinate with the Patient Tracking Manager regarding: Receiving and screening inquiries regarding the status of individual patients. Release of appropriate information to appropriate requesting entities. Continue to document all actions and observations on the Operational Log (HICS Form 214) on a continual basis. Extended (Operational Period Beyond 12 Hours) Time Initial Continue to receive regular progress reports from the Incident Commander, Section Chiefs and others, as appropriate. Coordinate with the Logistics Section Chief to determine requests for assistance to be released to the public via the media. With approval from Incident Commander and in collaboration with community and governmental PIOs, conduct ongoing news conferences, providing updates on casualty information and hospital operational status to the news media. Facilitate staff and patient interviews as appropriate. Ensure ongoing information coordination with other agencies, hospitals, local EOC and the JIC. Prepare and maintain records and reports as indicated or requested. Ensure your physical readiness through proper nutrition, water intake, rest, and stress management techniques. Observe all staff and volunteers for signs of stress and inappropriate behavior. Report concerns to the Employee Health & Well-Being Unit. Upon shift change, brief your replacement on the status of all ongoing operations, issues, and other relevant incident information. Section VII: Page 12 of 138

91 Demobilization/System Recovery Time Initial As needs for Public Information team staff decrease, return staff to their normal jobs and combine or deactivate positions in a phased manner. Coordinate release of final media briefings and reports. Ensure return/retrieval of equipment and supplies and return all assigned incident command equipment. Upon deactivation of your position, brief the Incident Commander on current problems, outstanding issues, and follow-up requirements. Upon deactivation of your position, submit Operational Logs (HICS Form 214) and all completed documentation to the Planning Section Chief. Participate in after-action debriefings and document observations and recommendations for improvements for possible inclusion in the After-Action Report. Topics include: Accomplishments and issues Review of pertinent position descriptions and operational checklists Recommendations for procedure changes Participate in stress management and after-action debriefings. Participate in other briefings and meetings as required. Documents/Tools Incident Action Plan HICS Form 207 Incident Management Team Chart HICS Form 213 Incident Message Form HICS Form 214 Operational Log Hospital emergency operations plan Crisis and emergency risk communication plan (Facility, and if available, community plan) Hospital organization chart Hospital telephone directory Radio/satellite phone Community and governmental PIO and Joint Information Center contact information Local media contact information Section VII: Page 13 of 138

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93 SAFETY OFFICER Mission: Ensure safety of staff, patients, and visitors, monitor and correct hazardous conditions. Have authority to halt any operation that poses immediate threat to life and health. Date: Start: End: Position Assigned to: Initials: Position Reports to: Incident Commander Signature: Hospital Command Center (HCC) Location: Telephone: Fax: Other Contact Info: Radio Title: Immediate (Operational Period 0-2 Hours) Time Initial Receive appointment and briefing from the Incident Commander. Read this entire Job Action Sheet and review incident management team chart (HICS Form 207). Put on position identification. Notify your usual supervisor of your HICS assignment. Establish contact with the Communications Unit Leader and confirm your contact information. Appoint Safety team members and complete the Branch Assignment List (HICS Form 204). Brief team members on current situation and incident objectives; develop response strategy and tactics; outline action plan and designate time for next briefing. Determine safety risks of the incident to personnel, the hospital facility, and the environment. Advise the Incident Commander and Section Chiefs of any unsafe condition and corrective recommendations. Communicate with the Logistics Chief to procure and post non-entry signs around unsafe areas. Ensure the following activities are initiated as indicated by the incident/situation: Evaluate building or incident hazards and identify vulnerabilities Specify type and level of PPE to be utilized by staff to ensure their protection, based upon the incident or hazardous condition Establish a Hazardous Materials Command Post, in collaboration with the Operations Section s Hazardous Materials Branch Director Monitor operational safety of decontamination operations Ensure that Safety staff identify and report all hazards and unsafe conditions to the Operations Section Chief Assess hospital operations and practices of staff, and terminate and report any unsafe operation or practice, recommending corrective actions to ensure safe service delivery. Initiate the Incident Action Plan Safety Analysis (HICS Form 261). Ensure implementation of all safety practices and procedures in the hospital. Initiate environmental monitoring as indicated by the incident or hazardous condition. Attend all command briefings and Incident Action Planning meetings to gather and share incident and hospital/facility safety requirements. Request one or more recorders as needed from the Labor Pool & Credentialing Unit Leader, if activated, to perform documentation and tracking. Section VII: Page 14 of 138

94 Immediate (Operational Period 0-2 Hours) Time Initial Document all key activities, actions, and decisions in an Operational Log (HICS Form 214) on a continual basis. Document all communications (internal and external) on an Incident Message Form (HICS Form 213). Provide a copy of the Incident Message Form to the Documentation Unit. Intermediate (Operational Period 2-12 Hours) Time Initial Attend all command briefings and Incident Action Planning meetings to gather and share incident and hospital/facility information. Contribute safety issues, activities and goals to the Incident Action Plan. Continue to assess safety risks of the incident to personnel, the hospital facility, and the environment. Advise the Incident Commander and Section Chiefs of any unsafe condition and corrective recommendations. Ensure proper equipment needs are met and equipment is operational prior to each operational period. Continue to document all actions and observations on the Operational Log (HICS Form 214) on a continual basis. Extended (Operational Period Beyond 12 Hours) Time Initial Re-assess the safety risks of the extended incident to personnel, the hospital facility, and the environment and report appropriately. Advise the Incident Commander and Section Chiefs of any unsafe condition and corrective recommendations. Continue to update the Incident Action Plan Safety Analysis (HICS Form 261) for possible inclusion in the facility/hospital Incident Action Plan. Continue to assess hospital operations and practices of staff, and terminate and report any unsafe operation or practice, recommending corrective actions to ensure safe service delivery. Continue to attend all command briefings and incident action planning meetings to gather and share incident and hospital/facility information. Contribute safety issues, activities and goals to the Incident Action Plan. Ensure your physical readiness through proper nutrition, water intake, rest, and stress management techniques. Observe all staff and volunteers for signs of stress and inappropriate behavior. Report concerns to the Employee Health & Well-Being Unit. Upon shift change, brief your replacement on the status of all ongoing operations, issues, and other relevant incident information. Demobilization/System Recovery Time Initial As needs for Safety team staff decrease, return staff to their normal jobs and combine or deactivate positions in a phased manner. Ensure return/retrieval of equipment and supplies and return all assigned incident command equipment. Upon deactivation of your position, brief the Incident Commander on current problems, outstanding issues, and follow-up requirements. Upon deactivation of your position, submit Operational Logs (HICS Form 214) and all completed documentation to the Planning Section Chief. Participate in after-action debriefings and document observations and recommendations for improvements for possible inclusion in the After-Action Report. Topics include: Accomplishments and issues Section VII: Page 15 of 138

95 Demobilization/System Recovery Time Initial Review of pertinent position descriptions and operational checklists Recommendations for procedure changes Participate in stress management and after-action debriefings. Participate in other briefings and meetings as required. Documents/Tools Incident Action Plan HICS Form 207 Incident Management Team Chart HICS Form 213 Incident Message Form HICS Form 214 Operational Log HICS Form 261 Incident Action Plan Safety Analysis Hospital emergency operations plan Hospital organization chart Hospital telephone directory Radio/satellite phone Material safety data sheets (MSDS) or other information regarding involved chemicals (ATSDR, CHEMTREC, NIOSH handbook) Section VII: Page 16 of 138

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97 LIAISON OFFICER Mission: Function as the incident contact person in the Hospital Command Center for representatives from other agencies. Date: Start: End: Position Assigned to: Initial: Position Reports to: Incident Commander Signature: Initial: Hospital Command Center (HCC) Location: Telephone: Fax: Other Contact Info: Radio Title: Immediate (Operational Period 0-2 Hours) Time Initial Receive appointment and briefing from the Incident Commander. Read this entire Job Action Sheet and review incident management team chart (HICS Form 207). Put on position identification. Notify your usual supervisor of your HICS assignment. Appoint Liaison team members and complete the Branch Assignment List (HICS Form 204). Brief Liaison team members on current situation and incident objectives; develop response strategy and tactics; outline action plan and designate time for next briefing. Establish contact with the Communications Unit Leader, and confirm your contact information. Establish contact with local, county and/or state emergency organization agencies to ascertain current status, appropriate contacts and message routing. Consider need to deploy a Liaison Officer to local EOC; make recommendation to the Incident Commander. Communicate information obtained and coordinate with Public Information Officer. Obtain initial status and information from the Planning Section Chief to provide as appropriate to the interhospital emergency communication network and local and/or county EOC, upon request: Patient Care Capacity The number of immediate (red), delayed (yellow), and minor (green) patients that can be received and treated immediately, and current census. Hospital s Overall Status Current condition of hospital structure, security, and utilities. Any current or anticipated shortage critical resources including personnel, equipment, supplies, medications, etc. Number of patients and mode of transportation for patients requiring transfer to other hospitals, if applicable. Any resources that are requested by other facilities (e.g., personnel, equipment, supplies, medications, etc.). Media relations efforts being initiated, in conjunction with the PIO. Establish communication with other hospitals, local Emergency Operations Center (EOC), and/or local response agencies (e.g., public health). Report current hospital status. Establish contact with liaison counterparts of each assisting and cooperating agency (e.g., local EOC, Red Cross), keeping governmental Liaison Officers updated on changes in facility/hospital status, initial hospital response to incident, critical issues and resource needs. Request one or more recorders as needed from the Labor Pool and Credentialing Unit Leader, if activated, to perform all necessary documentation. Section VII: Page 17 of 138

98 Immediate (Operational Period 0-2 Hours) Time Initial Document all key activities, actions, and decisions in an Operational Log (HICS Form 214) on a continual basis. Document all communications (internal and external) on an Incident Message Form (HICS Form 213). Provide a copy of the Incident Message Form to the Documentation Unit. Intermediate (Operational Period 2-12 Hours) Time Initial Attend all command briefings and Incident Action Planning meetings to gather and share incident and hospital/facility information. Contribute inter-hospital information and community response activities and provide Liaison goals to the Incident Action Plan. Request assistance and information as needed through the inter-hospital emergency communication network or from the local and/or regional EOC. Consider need to deploy a Liaison Officer to the local EOC; make this recommendation to the Incident Commander. Obtain Hospital Casualty/Fatality Report (HICS Form 259) from the Public Information Officer and Planning Section Chief and report to appropriate authorities the following minimum data: Number of casualties received and types of injuries treated. Current patient capacity (census) Number of patients hospitalized, discharged home, or transferred to other facilities. Number dead. Individual casualty data: name or physical description, sex, age, address, seriousness of injury or condition. Respond to requests and issues from incident management team members regarding inter-organization (e.g., other hospitals, governmental entities, response partners) problems. Assist the Labor Pool & Credentialing Team Leader with problems encountered in the volunteer credentialing process. Report any special information obtained (e.g., identification of toxic chemical, decontamination or any special emergency condition) to appropriate personnel in the receiving area of the hospital (e.g., emergency department), HCC and/or other receiving facilities. Continue to document all actions and observations on the Operational Log (HICS Form 214) on a continual basis. Extended (Operational Period Beyond 12 Hours) Time Initial In coordination with the Labor Pool & Credentialing Unit Leader and the local EOC, request physicians and other hospital staff willing to volunteer as Disaster Service Workers outside of the hospital, when appropriate. Communicate with Logistics Section Chief on status of supplies, equipment and other resources that could be mobilized to other facilities, if needed or requested. Consider need to deploy/maintain a Liaison Officer to local EOC; make the recommendation to the Incident Commander. Prepare and maintain records and reports as appropriate. Ensure your physical readiness through proper nutrition, water intake, rest, and stress management techniques. Observe all staff and volunteers for signs of stress and inappropriate behavior. Report concerns to the Employee Health & Well-Being Unit. Section VII: Page 18 of 138

99 Extended (Operational Period Beyond 12 Hours) Time Initial Upon shift change, brief your replacement on the status of all ongoing operations, issues, and other relevant incident information. Demobilization/System Recovery Time Initial As needs for Liaison team staff decrease, return staff to their normal jobs and combine or deactivate positions in a phased manner. Ensure return/retrieval of equipment and supplies and return all assigned incident command equipment. Upon deactivation of your position, brief the Incident Commander on current problems, outstanding issues, and follow-up requirements. Upon deactivation of your position, submit Operational Logs (HICS Form 214) and all completed documentation to the Planning Section Chief. Participate in after-action debriefings and document observations and recommendations for improvements for possible inclusion in the After-Action Report. Topics include: Accomplishments and issues Review of pertinent position descriptions and operational checklists Recommendations for procedure changes Participate in stress management and after-action debriefings. Participate in other briefings and meetings as required. Documents/Tools Incident Action Plan HICS Form 207 Incident Management Team Chart HICS Form 213 Incident Message Form HICS Form 214 Operational Log HICS Form 259 Hospital Casualty/Fatality Report Hospital emergency operations plan Hospital organization chart Hospital telephone directory Radio/satellite phone Municipal organization chart and contact numbers County organization chart and contact numbers Section VII: Page 19 of 138

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101 OPERATIONS SECTION CHIEF Mission: Develop and implement strategy and tactics to carry out the objectives established by the Incident Commander. Organize, assign, and supervise Staging, Medical Care, Infrastructure, Security, Hazardous Materials, and Business Continuity Branch resources. Date: Start: End: Position Assigned to: Initial: Position Reports to: Incident Commander Signature: Hospital Command Center (HCC) Location: Telephone: Fax: Other Contact Info: Radio Title: Immediate (Operational Period 0-2 Hours) Time Initial Receive appointment and briefing from the Incident Commander. Obtain packet containing Operations Section Job Action Sheets. Read this entire Job Action Sheet and review incident management team chart (HICS Form 207). Put on position identification. Notify your usual supervisor of your HICS assignment. Determine need to appoint Staging Manager, Branch Directors, and Unit Leaders in Operations Section; distribute corresponding Job Action Sheets and position identification. Complete the Branch Assignment List (HICS Form 204). Brief Operations Section Branch Directors and Staging Manager on current situation and incident objectives; develop response strategy and tactics; outline Section action plan and designate time for next briefing. Participate in Incident Action Plan preparation, briefings, and meetings as needed; assist in identifying strategies; determine tactics, work assignments, and resource requirements. Obtain information and updates regularly from Operations Section Branch Directors and Staging Manager; maintain current status of all areas; inform Situation Unit Leader of status information. Maintain communications with Logistics Section Chief and Staging Manager to ensure the accurate movement and tracking of personnel and resources to Staging Area. Ensure Operations Section personnel comply with safety policies and procedures. Document all key activities, actions, and decisions in an Operational Log (HICS Form 214) on a continual basis. Document all communications (internal and external) on an Incident Message Form (HICS Form 213). Provide a copy of the Incident Message Form to the Documentation Unit. Intermediate (Operational Period 2-12 Hours) Time Initial Communicate regularly with the Incident Commander, Public Information Officer and Liaison Officer; brief regularly on the status of the Operations Section. Designate time(s) for briefings and updates with Operations Section leadership to develop or update the Section action plan. Ensure the following are being addressed: Section Staff health and safety Section VII: Page 20 of 138

102 Intermediate (Operational Period 2-12 Hours) Time Initial Patient tracking Patient care Patient family support Interfacility transfers (into and from facility) Fatality management Information sharing with local EOC, public health, and law enforcement in coordination with the Liaison Officer Personnel and resource movement through Staging Area Documentation Initiate the Resource Accounting Record (HICS Form 257) to track equipment used during the response. Schedule planning meetings with Branch Directors and Staging Manager to update the Section action plan and demobilization procedures. Coordinate patient care treatment standards and case definitions with public health officials, as appropriate. Ensure that the Operations Section is adequately staffed and supplied. Coordinate personnel needs with Labor Pool & Credentialing Unit Leader, supply and equipment needs with the Supply Unit Leader, projections and needs with the Planning Section, and financial matters with the Finance/Administration Section. Ensure coordination with any assisting or cooperating agency. Extended (Operational Period Beyond 12 Hours) Time Initial Continue to monitor Operations Section personnel s ability to meet workload demands, staff health and safety, resource needs and documentation practices. Continue to maintain the Resource Accounting Record (HICS Form 257) to track equipment used during the response. Conduct regular situation briefings with Operations Section Branch Directors and Staging Manager. Address issues related to ongoing patient care: Ongoing patient arrival Bed availability Patient transfers Patient tracking Staff health and safety Mental health for patients, families, staff, incident management personnel Fatality management Staffing Staff prophylaxis Medications Medical equipment and supplies Personnel and resource movement through Staging Area Linkages with the medical community, area hospitals, and other healthcare facilities Documentation Ensure your physical readiness through proper nutrition, water intake, rest, and stress management techniques. Observe all staff and volunteers for signs of stress and inappropriate behavior. Report concerns to the Employee Health & Well-Being Unit. Provide for staff rest periods and relief. Section VII: Page 21 of 138

103 Extended (Operational Period Beyond 12 Hours) Time Initial Upon shift change, brief your replacement on the status of all ongoing operations, issues, and other relevant incident information. Demobilization/System Recovery Time Initial As needs decrease, return Operations Section staff to their usual jobs and combine or deactivate positions in a phased manner, in coordination with the Demobilization Unit Leader. Coordinate patient care restoration to normal services. Coordinate final reporting of patient information with external agencies through Liaison Officer and Public Information Officer. Work with Planning and Finance/Administration Sections to complete cost data information. Debrief staff on lessons learned and procedural/equipment changes needed. Upon deactivation of your position, brief the Incident Commander on current problems, outstanding issues, and follow-up requirements. Upon deactivation of your position, ensure all documentation and Operational Logs (HICS Form 214) are submitted to the Documentation Unit. Submit comments to the Incident Commander for discussion and possible inclusion in an after-action report; topics include: Review of pertinent position descriptions and operational checklists Recommendations for procedure changes Section accomplishments and issues Participate in stress management and after-action debriefings. Participate in other briefings and meetings as required. Documents/Tools Incident Action Plan HICS Form 204 Branch Assignment Sheet HICS Form 207 Incident Management Team Chart HICS Form 213 Incident Message Form HICS Form 214 Operational Log HICS Form 257 Resource Accounting Record Hospital emergency operations plan Hospital organization chart Hospital telephone directory Radio/satellite phone Section VII: Page 22 of 138

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105 STAGING MANAGER Mission: Organize and manage the deployment of supplementary resources, including personnel, vehicles, equipment, supplies, and medications. Date: Start: End: Position Assigned to: Initial: Position Reports to: Operations Section Chief Signature: Hospital Command Center (HCC) Location: Telephone: Fax: Other Contact Info: Radio Title: Immediate (Operational Period 0-2 Hours) Time Initial Receive appointment and briefing from the Operations Section Chief. Obtain Staging Unit Job Action Sheets. Read this entire Job Action Sheet and review incident management team chart (HICS Form 207). Put on position identification. Notify your usual supervisor of your HICS assignment. Determine need for and appropriately appoint Staging Team Leaders, distribute corresponding Job Action Sheets and position identification. Complete the Branch Assignment List (HICS Form 204). Document all key activities, actions, and decisions in an Operational Log (HICS Form 214) on a continual basis. Brief the Staging Team Leaders on current situation; outline branch action plan and designate time for next briefing. Identify an appropriate area to serve as Staging Area for the receipt and distribution of personnel and equipment resources. Coordinate delivery of needed resources to requesting area: Personnel Vehicles Equipment and supplies Medications Regularly report Staging Area status to Operation Section Chief. Assess problems and needs; coordinate resource management. Instruct all Staging Team Leaders to evaluate on-hand equipment, supply, and medication inventories and staff needs in collaboration with Logistics Section Supply Unit Leader; report status to Operations Section Chief and Supply Unit. Meet with the Operations Section Chief and Logistics Section Chief, as appropriate to discuss plan of action and staffing in all activities. Document all communications (internal and external) on an Incident Message Form (HICS Form 213). Provide a copy of the Incident Message Form to the Documentation Unit. Intermediate (Operational Period 2-12 Hours) Time Initial Meet regularly with the Operations Section Chief for status reports, and relay important information to Staging Team staff. Section VII: Page 23 of 138

106 Intermediate (Operational Period 2-12 Hours) Time Initial Continue coordinating delivery of needed personnel, equipment/supplies, medications, and facility support services, working with the Logistics Section and Operations Section Branch Directors, as needed. Ensure prioritization of problems when multiple issues are presented. Coordinate use of external resources. Develop and submit a Staging Area action plan to the Operations Section Chief when requested. Ensure documentation is completed correctly and collected. Advise the Operations Section Chief immediately of any operational issue you are not able to correct or resolve. Make notification of resource problems encountered to the Logistics Section Chief, as appropriate. Ensure staff health and safety issues being addressed; resolve with the Safety Officer. Extended (Operational Period Beyond 12 Hours) Time Initial Continue to monitor the Staging Team s ability to meet workload demands, staff health and safety, resource needs, and documentation practices. Coordinate assignment and orientation of external personnel sent to assist. Work with the Operations Section Chief and Logistics Section Chief, as appropriate on the assignment of external resources. Rotate staff on a regular basis. Document actions and decisions on a continual basis. Continue to provide the Operations Section Chief with periodic situation updates. Ensure your physical readiness through proper nutrition, water intake, rest, and stress management techniques. Observe all staff and volunteers for signs of stress and inappropriate behavior. Report concerns to the Employee Health & Well-Being Unit Leader. Provide for staff rest periods and relief. Upon shift change, brief your replacement on the status of all ongoing operations, issues, and other relevant incident information. Demobilization/System Recovery Time Initial As needs for Staging Area decrease, return staff to their normal jobs and combine or deactivate positions in a phased manner, in coordination with the Demobilization Unit Leader. Assist the Operations Section Chief and Branch Directors with restoring hospital resources to normal operating condition. Ensure the return/retrieval of equipment/supplies/personnel. Debrief staff on lessons learned and procedural/equipment changes needed. Upon deactivation of your position, brief the Operations Section Chief on current problems, outstanding issues, and follow-up requirements. Upon deactivation of your position, ensure all documentation and Staging Unit Operational Logs (HICS Form 214) are submitted to the Operations Section Chief. Submit comments to the Operations Section Chief for discussion and possible inclusion in the after-action Section VII: Page 24 of 138

107 Demobilization/System Recovery Time Initial report; topics include: Review of pertinent position descriptions and operational checklists Recommendations for procedure changes Section accomplishments and issues Participate in stress management and after-action debriefings. Participate in other briefings and meetings as required. Documents/Tools Incident Action Plan HICS Form 204 Branch Assignment List HICS Form 207 Incident Management Team Chart HICS Form 213 Incident Message Form HICS Form 214 Operational Log Hospital emergency operations plan Hospital organization chart Hospital telephone directory Radio/satellite phone Section VII: Page 25 of 138

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109 MEDICAL CARE BRANCH DIRECTOR Mission: Organize and manage the delivery of emergency, inpatient, outpatient, and casualty care, and clinical support services. Date: Start: End: Position Assigned to: Initial: Position Reports to: Operations Section Chief Signature: Hospital Command Center (HCC) Location: Telephone: Fax: Other Contact Info: Radio Title: Immediate (Operational Period 0-2 Hours) Time Initial Receive appointment and briefing from the Operations Section Chief. Obtain packet containing Medical Care Branch Job Action Sheets. Read this entire Job Action Sheet and review incident management team chart (HICS Form 207). Put on position identification. Notify your usual supervisor of your HICS assignment. Determine need for and appropriately appoint Medical Care Branch Unit Leaders, distribute corresponding Job Action Sheets and position identification. Complete the Branch Assignment List (HICS Form 204). Document all key activities, actions, and decisions in an Operational Log (HICS Form 214). Collaborate with Medical/Technical Specialist(s) concerning medical care guidance. Brief the Medical Care Branch Unit Leaders on current situation, incident objectives and strategy; outline Branch action plan and designate time for next briefing. Evaluate Medical Care Branch capacity to perform: Inpatient Outpatient Casualty Care Mental Health Clinical Support Services (lab, diagnostic radiology, pharmacy) Patient Registration Ensure new patients are being rapidly assessed and moved to definitive care locations (i.e., admission, surgery, discharge, transfer.) Ensure pre-existing patients receive needed care and reassurance. Assess problems and needs in Branch areas; coordinate resource management. Ensure Branch personnel comply with safety policies and procedures. Instruct all Unit Leaders to evaluate on-hand equipment, supply, and medication inventories and staff needs in collaboration with Logistics Section Branches; report status to the Operations Section Chief. Determine need for surge capacity plan implementation and/or modification of existing plan. Coordinate with Inpatient and Casualty Care Unit Leaders to prioritize patient transfer needs. Determine if communicable disease risk exists; implement appropriate response procedure(s). Collaborate with the appropriate Medical/Technical Specialist, if activated. Section VII: Page 26 of 138

110 Immediate (Operational Period 0-2 Hours) Time Initial Regularly meet with the Operations Section Chief to discuss plan of action and staffing in all service areas. Document all communications (internal and external) on an Incident Message Form (HICS Form 213). Provide a copy of the Incident Message Form to the Documentation Unit. Intermediate (Operational Period 2-12 Hours) Time Initial Continue to meet regularly with Operations Section Chief for status reports, and relay important information to Branch staff. Continue coordinating patient care, disposition of patients, and clinical services support. Ensure patient transfer coordination and tracking is being done according to the Emergency Operations Plan and hospital procedures. Ensure patient records are being done correctly and collected. Ensure patient care needs are being met and policy decisions to institute austere care (altered level of care) practices are determined and communicated effectively. Advise the Operations Section Chief immediately of any operational issue you are not able to correct or resolve. Assess environmental services (housekeeping) needs in all clinical care and clinical support areas; contact the Infrastructure Branch Leader or Environmental Services Unit Leader, as appropriate, with identified needs. Review personnel protection practices; revise as needed. Ensure patient safety issues are identified and addressed. Report equipment and supply needs to Operations and Logistics Section Chiefs. Continue to provide updated clinical information and situation reports to Unit Leaders and staff. Ensure patient data is collected and shared with appropriate internal and external officials, in collaboration with the Liaison Officer. Ensure staff health and safety issues are being addressed; resolve with the Safety Officer and Employee Health & Well-Being Unit, as appropriate. Develop and submit a Branch action plan to the Operations Section Chief when requested. Communicate with Clinical Support Services Unit Leader to ensure accurate routing of test results. Extended (Operational Period Beyond 12 Hours) Time Initial Continue to monitor Medical Care Branch s ability to meet workload demands, staff health and safety, resource needs, and documentation practices. Continue to ensure patient transfer coordination and tracking; mitigate identified issues. Rotate staff on a regular basis. Continue to document actions and decisions on an Operational Log (HICS Form 214) and submit to the Operations Section Chief at assigned intervals and as needed. Continue to provide the Operations Section Chief with regular situation updates. Provide Branch Unit Leaders with situation update information and revised patient care practice standards. Section VII: Page 27 of 138

111 Extended (Operational Period Beyond 12 Hours) Time Initial Ensure your physical readiness through proper nutrition, water intake, rest, and stress management techniques. Observe all staff and volunteers for signs of stress and inappropriate behavior. Report concerns to the Employee Health & Well-Being Unit Leader. Provide for staff rest periods and relief. Upon shift change, brief your replacement on the status of all ongoing operations, issues, and other relevant incident information. Demobilization/System Recovery Time Initial As needs for Medical Care Branch staff decrease, return staff to their usual jobs, and combine or deactivate positions in a phased manner. Assist Operations Section Chief and Unit Leaders with restoring patient care and clinical support areas to normal operations. Notify the Operations Section Chief when restoration is complete. Ensure return/retrieval of equipment and supplies and return all assigned incident command equipment. Debrief staff on lessons learned and procedural/equipment changes needed. Upon deactivation of your position, brief the Operations Section Chief on current problems, outstanding issues, and follow-up requirements. Upon deactivation of your position, ensure all documentation and Operational Logs (HICS Form 214) are submitted to the Operations Section Chief. Submit comments to the Operations Section Chief for discussion and possible inclusion in the after-action report; topics include: Review of pertinent position descriptions and operational checklists Recommendations for procedure changes Section accomplishments and issues Participate in stress management and after-action debriefings. Participate in other briefings and meetings as required. Documents/Tools Incident Action Plan HICS Form 204 Branch Assignment List HICS Form 207 Incident Management Team Chart HICS Form 213 Incident Message Form HICS Form 214 Operational Log Hospital emergency operations plan Hospital organization chart Hospital telephone directory Radio/satellite phone Section VII: Page 28 of 138

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113 INFRASTRUCTURE BRANCH DIRECTOR Mission: Organize and manage the services required to sustain and repair the hospital s infrastructure operations, including: power/lighting, water/sewer, HVAC, buildings and grounds, medical gases, medical devices, structural integrity, environmental services, and food services. Date: Start: End: Position Assigned to: Initial: Position Reports to: Operations Section Chief Signature: Hospital Command Center (HCC) Location: Telephone: Fax: Other Contact Info: Radio Title: Immediate (Operational Period 0-2 Hours) Time Initial Receive appointment and briefing from the Operations Section Chief. Obtain packet containing Infrastructure Branch Job Action Sheets. Read this entire Job Action Sheet and review incident management team chart (HICS Form 207). Put on position identification. Notify your usual supervisor of your HICS assignment. Appoint Infrastructure Branch Unit Leaders and complete the Branch Assignment List (HICS Form 204). Brief the Infrastructure Branch on current situation, incident objectives and strategy; outline Branch action plan and designate time for next briefing. Document all key activities, actions, and decisions in an Operational Log (HICS Form 214) on a continual basis. Assess Infrastructure Branch capacity to deliver needed: Facility heating and air conditioning Power Telecommunications Potable and non-potable water Medical gas delivery Sanitation Road clearance Damage assessment and repair Facility cleanliness Vertical transport Facility access Assess problems and needs in Branch area; coordinate resource management. Ensure Branch personnel comply with safety policies and procedures. Instruct all Unit Leaders to evaluate on-hand equipment, supply, and medication inventories and staff needs, in collaboration with Logistics Section s Service and Support Branches or Units, as appropriate; report status to the Operations Section Chief and the Support Branch or Supply Unit Leader, as appropriate. Meet regularly with the Operations Section Chief to discuss plan of action and staffing. Initiate facility damage assessment in collaboration with Logistics Section s Facilities Unit, if warranted; repair problems encountered, and update the Operations Section Chief of the situation. Assist in completion of the Facility System Status Report (HICS Form 251) Section VII: Page 29 of 138

114 Immediate (Operational Period 0-2 Hours) Time Initial Document all communications (internal and external) on an Incident Message Form (HICS Form 213). Provide a copy of the Incident Message Form to the Documentation Unit. Intermediate (Operational Period 2-12 Hours) Time Initial Continue coordinating facility support services. Ensure prioritization of problems when multiple issues are presented. Ensure documentation records are completed correctly and collected. Coordinate use of external resources to assist with maintenance and repairs. Report equipment needs to the Supply Unit Leader. Supervise salvage operations with the Operations Section Chief, if indicated. Ensure staff health and safety issues are being addressed; resolve with Infrastructure Branch Director, Safety Officer and Employee Health and Well-Being Unit Leader. Develop and submit a Branch action plan to the Operations Section Chief when requested. Advise the Operations Section Chief immediately of any operational issue you are not able to correct or resolve. Meet regularly with Operations Section Chief for status reports, and relay important information to Branch staff. Continue coordinating facility support services. Ensure documentation and records are being completed correctly and collected. Extended (Operational Period Beyond 12 Hours) Time Initial Continue to monitor the Infrastructure Branch s ability to meet workload demands, staff health and safety, resource needs, and documentation practices. Rotate staff on a regular basis. Continue to document actions and decisions on an Operational Log (HICS Form 214) and send to the Operations Section Chief at assigned intervals and as needed. Continue to provide the Operations Section Chief with regular situation updates. Ensure your physical readiness through proper nutrition, water intake, rest, and stress management techniques. Observe all staff and volunteers for signs of stress and inappropriate behavior. Report concerns to the Employee Health & Well-Being Unit Leader. Provide for staff rest periods and relief. Upon shift change, brief your replacement on the status of all ongoing operations, issues, and other relevant incident information. Section VII: Page 30 of 138

115 Demobilization/System Recovery Time Initial As needs for Infrastructure Branch staff decrease, return staff to their usual jobs, and combine or deactivate positions in a phased manner. Assist the Operations Section Chief and Branch Directors with restoring hospital infrastructure services to normal operating condition. Ensure return/retrieval of equipment and supplies and return all assigned incident command equipment. Upon deactivation of your position, brief the Operations Section Chief on current problems, outstanding issues, and follow-up requirements. Upon deactivation of your position, ensure all documentation and Operational Logs (HICS Form 214) are submitted to the Operations Section Chief. Debrief staff on lessons learned and procedural/equipment changes needed Submit comments to the Operations Section Chief for discussion and possible inclusion in the after-action report; topics include: Review of pertinent position descriptions and operational checklists Recommendations for procedure changes Section accomplishments and issues Participate in stress management and after-action debriefings. Participate in other briefings and meetings as required. Documents/Tools Incident Action Plan HICS Form 204 Branch Assignment List HICS Form 207 Incident Management Team Chart HICS Form 213 Incident Message Form HICS Form 214 Operational Log Hospital emergency operations plan Hospital organization chart Hospital telephone directory Radio/satellite phone Facility maps and ancillary services schematics Vendor support and repair directory Section VII: Page 31 of 138

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117 HAZARDOUS MATERIALS BRANCH DIRECTOR Mission: Organize and direct hazardous material incident response activities: detection and monitoring; spill response; victim, technical, and emergency decontamination; and facility and equipment decontamination. Date: Start: End: Position Assigned to: Initial: Position Reports to: Operations Section Chief Signature: Hospital Command Center (HCC) Location: Telephone: Fax: Other Contact Info: Radio Title: Immediate (Operational Period 0-2 Hours) Time Initial Receive appointment and briefing from the Operations Section Chief. Obtain packet containing Hazardous Materials Branch Job Action Sheets. Read this entire Job Action Sheet and review incident management team chart (HICS Form 207). Put on position identification. Notify your usual supervisor of your HICS assignment. Determine need for and appropriately appoint Hazardous Materials Branch Unit Leaders; distribute corresponding Job Action Sheets and position identification. Complete the Branch Assignment List (HICS Form 204). Document all key activities, actions, and decisions in an Operational Log (HICS Form 214) on a continual basis. Brief the Hazardous Materials Branch on current situation, incident objectives and strategy; outline Branch action plan and designate time for next briefing. Ensure Branch personnel comply with safety policies and procedures. Obtain hazardous materials agent information and notify Hazardous Materials Branch Unit Leaders, hospital emergency department, and other treatment areas. Evaluate special response needs to include: coordination with local or area external hazardous materials teams level and type of decontamination needed (e.g., dry, radiological, technical, gross) Ensure hazard monitoring in open and enclosed spaces; coordinate with the Safety Officer. Ensure hospital's internal spill response plan is activated, as appropriate. Ensure the set-up and staffing of decontamination areas, as appropriate to incident. Ensure mass decontamination system is functional and meets decontamination needs. Ensure appropriate antidote supplies are delivered to the decontamination area. Coordinate with the Supply Unit Leader and Clinical Support Services Unit. Review antidote administration procedure(s) with decontamination personnel, if needed. Establish medical monitoring of decontamination team members; coordinate with the Employee Health & Well-Being Unit Leader. Document all communications (internal and external) on an Incident Message Form (HICS Form 213). Provide a copy of the Incident Message Form to the Documentation Unit. Section VII: Page 32 of 138

118 Immediate (Operational Period 0-2 Hours) Time Initial Ensure patient valuables are collected and secured; coordinate with the Security Branch Director. Determine special equipment and supply needs; request from the Supply Unit Leader and report of Operations Section Chief. Notify local water authority of situation, as appropriate, and determine if containment of any run-off is required. Ensure proper wastewater collection and disposal, in compliance with recommendations from water authority, emergency management, and/or local hazardous material team/fire department. Make requests for external assistance as needed, in coordination with the Liaison Officer. Intermediate (Operational Period 2-12 Hours) Time Initial Meet regularly with Operations Section Chief for status reports, and relay important information to Branch staff. Ensure staff are rotated and replaced as needed. Track results of medical monitoring of staff, in collaboration with the Employee Health and Well-Being Unit Leader. Activate supplemental staffing plan as indicated. Ensure hazard monitoring continues and issues are addressed; coordinate with the Safety Officer. Continue to maintain chain of custody of all patient valuables and contaminated clothing in coordination with the Security Branch Director. Ensure decontamination supplies and PPE are replaced as needed. Ensure contaminated materials are disposed of properly. Prepare for the possibility of evacuation and/or the relocation of the decontamination area as needed. Receive regularly updated reports from Hazardous Materials Branch Team Leaders. Consult with Medical/Technical Specialist as needed to provide updated clinical management information to appropriate areas as available. Communicate status with external authorities, as appropriate, in coordination with the Liaison Officer. Coordinate internal repair activities, consulting when needed with Infrastructure Branch Director. Develop and submit a Branch action plan to the Operations Section Chief when requested. Advise Operations Section Chief immediately of any operational issue you are not able to correct or resolve. Extended (Operational Period Beyond 12 Hours) Time Initial Monitor levels of all supplies, equipment, and needs relevant to all hazardous material incident response operations, in collaboration with Supply Unit Leader. Address patient valuables issues; coordinate with the Security Branch Director. Brief the Operations Section Chief regularly on current condition; communicate needs in advance. Section VII: Page 33 of 138

119 Extended (Operational Period Beyond 12 Hours) Time Initial Continue to monitor facility operations and personnel reports impacting Branch status. Continue communication with appropriate external authorities; coordinate with the Liaison Officer. Ensure your physical readiness through proper nutrition, water intake, rest, and stress management techniques. Observe all staff and volunteers for signs of stress and inappropriate behavior. Report concerns to the Employee Health & Well-Being Unit Leader. Provide for staff rest periods and relief. Upon shift change, brief your replacement on the status of all ongoing operations, issues, and other relevant incident information. Demobilization/System Recovery Time Initial As needs for Hazardous Material Branch staff decrease, return staff to their usual jobs and combine or deactivate positions in a phased manner. Manage and secure patient belongings and valuables according to hospital policy; consult with Safety officer, Security Branch Director and local fire and law enforcement, as appropriate. Ensure the Hazardous Materials Branch Units are notified to terminate operations. Ensure the decontamination equipment is cleaned, repaired, and replaced as needed. Ensure proper disposal of waste material; coordinate cost issues with the Finance/Administration Section. Ensure disposable materials and waste are properly managed. Address the return of patient valuables with the Security Branch Director, local law enforcement, fire department, and hazardous materials teams. Ensure the decontamination areas are decontaminated, commensurate with agent and regulatory guidelines. Ensure medical monitoring data is collected and submitted to Employee Health & Well-Being Unit for review and entry into personnel health files. Ensure medical surveillance of staff is initiated as needed and/or per recommendations of internal/external experts, in collaboration with Employee Health & Well-Being Unit. Ensure return/retrieval of equipment and supplies and return all assigned incident command equipment. Notify Operations Section Chief when clean-up/restoration is complete. Debrief staff on lessons learned and procedural/equipment changes needed. Upon deactivation of your position, ensure all documentation and Operational Logs (HICS Form 214) are submitted to the Operations Section Chief. Upon deactivation of your position, brief the Operations Section Chief on current problems, outstanding issues, and follow-up requirements. Submit comments to the Operations Section Chief for discussion and possible inclusion in the after-action report; topics include: Review of pertinent position descriptions and operational checklists Recommendations for procedure changes Section accomplishments and issues Participate in stress management and after-action debriefings. Participate in other briefings and meetings as required. Section VII: Page 34 of 138

120 Documents/Tools Incident Action Plan HICS Form 204 Branch Assignment Sheet HICS Form 207 Incident Management Team Chart HICS Form 213 Incident Message Form HICS Form 214 Operational Log Hospital emergency operations plan Hospital organization chart Hospital telephone directory Radio/satellite phone OSHA First Receiver s Checklist Decontamination area drawings, procedures, and documentation logs Section VII: Page 35 of 138

121 SECURITY BRANCH DIRECTOR Mission: Coordinate all of the activities related to personnel and facility security such as access control, crowd and traffic control, and law enforcement interface. Date: Start: End: Position Assigned to: Initial: Position Reports to: Operations Section Chief Signature: Hospital Command Center (HCC) Location: Telephone: Fax: Other Contact Info: Radio Title: Immediate (Operational Period 0-2 Hours) Time Initial Receive appointment and briefing from the Operations Section Chief. Obtain packet containing Security Branch Job Action Sheets. Read this entire Job Action Sheet and review incident management team chart (HICS Form 207). Put on position identification. Notify your usual supervisor of your HICS assignment. Document all key activities, actions, and decisions in an Operational Log (HICS Form 214) on a continual basis. Determine need for and appropriately appoint Security Branch Unit Leaders, distribute corresponding Job Action Sheets and position identification. Complete the Branch Assignment List (HICS Form 204). Establish Security Command Post. Identify and secure all facility pedestrian and traffic points of entry, as appropriate. Consider need for the following, and report findings to the Operations Section Chief: Emergency lockdown Security/bomb sweep of designated areas Providing urgent security-related information to all personnel Need for security personnel to use personal protective equipment Removing unauthorized persons from restricted areas Security of the HCC, triage, patient care, morgue, and other sensitive or strategic areas from unauthorized access Rerouting of ambulance entry and exit Security posts in any operational decontamination area Patrol of parking and shipping areas for suspicious activity Traffic Control Brief the Security Branch on current situation, incident objectives and strategy; outline Branch action plan and designate time for next briefing. Ensure Branch personnel comply with safety policies and procedures and proper use of personal protective equipment, if applicable. Coordinate immediate security personnel needs from current staff, surrounding resources (police, sheriff, or other security forces), and communicate need for additional external resources through Operations Section Chief to the Liaison Officer. Assist in maximizing capability of the Branch to meet work demands. Assess problems and needs in Branch area; coordinate resource management. Section VII: Page 36 of 138

122 Immediate (Operational Period 0-2 Hours) Time Initial Participate in briefings and meetings as requested. Document all communications (internal and external) on an Incident Message Form (HICS Form 213). Provide a copy of the Incident Message Form to the Documentation Unit. Intermediate (Operational Period 2-12 Hours) Time Initial Meet regularly with Operations Section Chief for status reports, and relay important information to Branch staff. Communicate the need and take actions to secure unsafe areas; post non-entry signs. Ensure Security Branch staff identify and report all hazards and unsafe conditions. Ensure patient valuables are secure; initiate chain of custody procedures as necessary. Coordinate activities with local, state, and federal law enforcement, as appropriate; coordinate with the Liaison Officer and the Law Enforcement Interface Unit Leader. Confer with Public Information Officer to establish areas for the media. Ensure vehicular and pedestrian traffic control measures are working effectively. Consider security protection for the following, as indicated based on the nature/severity of the incident: Food Water Medical resources Blood resources Pharmaceutical resources Personnel and visitors Ensure proper equipment needs are met and equipment is operational prior to each operational period. Develop and submit a Branch action plan to the Operations Section Chief when requested. Advise the Operations Section Chief immediately of any operational issue you are not able to correct or resolve. Extended (Operational Period Beyond 12 Hours) Time Initial Continue to monitor Security Branch personnel s ability to meet workload demands, staff health and safety, resource needs, and documentation practices. Continue coordination with law enforcement officials. Prepare and maintain records and reports, as appropriate. Ensure your physical readiness through proper nutrition, water intake, rest, and stress management techniques. Observe all staff and volunteers for signs of stress and inappropriate behavior. Report concerns to the Employee Health & Well-Being. Provide for staff rest periods and relief. Upon shift change, brief your replacement on the status of all ongoing operations, issues, and other relevant incident information. Demobilization/System Recovery Time Initial Section VII: Page 37 of 138

123 Demobilization/System Recovery Time Initial As needs for Security Branch staff decrease, return staff to their usual jobs and combine or deactivate positions in a phased manner. Determine when to resume normal security procedures; ensure removal of special signage after all clear is announced. Determine with the Hazardous Materials Branch Director and other appropriate authorities the final disposition of patient valuables. Coordinate completion of work with law enforcement and Liaison Officer. Ensure return/retrieval of equipment and supplies and return all assigned incident command equipment. Ensure personal protective equipment used by Security is cleaned, repaired, and/or replaced. Debrief staff on lessons learned and procedural/equipment changes needed. Upon deactivation of your position, ensure all documentation and Operational Logs (HICS Form 214) are submitted to the Operations Section Chief. Upon deactivation of your position, brief the Operations Section Chief on current problems, outstanding issues, and follow-up requirements. Submit comments to the Operations Section Chief for discussion and possible inclusion in the after-action report; topics include: Review of pertinent position descriptions and operational checklists Recommendations for procedure changes Section accomplishments and issues Participate in stress management and after-action debriefings. Participate in other briefings and meetings as required. Documents/Tools Incident Action Plan HICS Form 204 Branch Assignment Sheet HICS Form 207 Incident Management Team Chart HICS Form 213 Incident Message Form HICS Form 214 Operational Log Hospital emergency operations plan Hospital organization chart Hospital telephone directory Radio/satellite phone Facility blueprints and maps Section VII: Page 38 of 138

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125 BUSINESS CONTINUITY BRANCH DIRECTOR Mission: Ensure business functions are maintained, restored or augmented to meet designated Recovery Time Objectives (RTO) and provide limited interruptions to continuity of essential business operations. Date: Start: End: Position Assigned to: Initial: Position Reports to: Operations Section Chief Signature: Hospital Command Center (HCC) Location: Telephone: Fax: Other Contact Info: Radio Title: Immediate (Operational Period 0-2 Hours) Time Initial Receive appointment and briefing from the Operations Section Chief. Obtain packet containing Business Continuity Branch Job Action Sheets. Read this entire Job Action Sheet and review incident management team chart (HICS Form 207). Put on position identification. Notify your usual supervisor of your HICS assignment. Document all key activities, actions, and decisions in an Operational Log (HICS Form 214) on a continual basis. Appoint Unit Leaders, as appropriate; distribute corresponding Job Action Sheets and identification. Brief the Business Continuity Branch on current situation, incident objectives and strategy; outline Branch action plan and designate time for next briefing. Evaluate Business Continuity Branch capacity to: Perform department and facility business continuity plan activation Determine ability to meet RTO for all impacted business functions Ascertain continuity of business functions including assessment of impacted areas Acquire access to essential business records (e.g., patient medical records, purchasing contracts, etc.) Support needed movement or relocation to alternate business operation sites Assess problems and needs in Branch area; coordinate resource management with Support Branch Director, as appropriate. Instruct Unit Leaders to evaluate business capabilities, recovery plan actions, and progress in meeting RTOs; report status to the Operations Section Chief. Participate in briefings and meetings as requested. Regularly meet with the Operations Section Chief to discuss plan of action and staffing. Receive, coordinate, and forward requests for IT and communications support to the Communications Unit Leader and IT/IS Unit Leader. Document all communications (internal and external) on an Incident Message Form (HICS Form 213). Provide a copy of the Incident Message Form to the Documentation Unit. Section VII: Page 39 of 138

126 Intermediate (Operational Period 2-12 Hours) Time Initial Meet regularly with Operations Section Chief for status reports, and relay important information to Branch staff. Continue coordinating the Business Continuity Branch s ability to maintain or recover impacted business functions. Evaluate all activated business continuity plans and modify as necessary any predicted unmet RTOs. Identify specific activities or resources needed to ensure timely resumption of business functions. Coordinate with the Infrastructure Branch Director for access to critical power needs or building assessments. Coordinate with the Security Branch Director for building access and staff safety Coordinate with the Service Branch Director or Communications Unit Leader and the IT/IS Unit Leader to ensure shared strategies for business resumption. Advise the Operations Section Chief immediately of any recovery issue you are not able to correct or resolve. Develop and submit a Branch action plan to the Operations Section Chief when requested. Extended (Operational Period Beyond 12 Hours) Time Initial Continue to monitor Business Continuity Branch s ability to maintain or recover impacted business functions Ensure your physical readiness through proper nutrition, water intake, rest, and stress management techniques. Observe all staff and volunteers for signs of stress and inappropriate behavior. Report concerns to the Employee Health & Well-Being. Provide for staff rest periods and relief. Upon shift change, brief your replacement on the status of all ongoing operations, issues, and other relevant incident information. Demobilization/System Recovery Time Initial As needs for Business Continuity Branch staff decrease, return staff to their usual jobs, and combine or deactivate positions in a phased manner. Assist Operations Section Chief and Branch Directors with restoring all business functions to normal operating condition. Notify the Operations Section Chief when restoration is complete. Ensure return/retrieval of equipment and supplies and return all assigned incident command equipment. Debrief staff on lessons learned and procedural/equipment changes needed. Upon deactivation of your position, ensure all documentation and Operational Logs (HICS Form 214) are submitted to the Operations Section Chief. Upon deactivation of your position, brief the Operations Section Chief on current problems, outstanding issues, and follow-up requirements. Submit comments to the Operations Section Chief for discussion and possible inclusion in the after-action report; topics include: Review of pertinent position descriptions and operational checklists Section VII: Page 40 of 138

127 Demobilization/System Recovery Time Initial Recommendations for procedure changes Section accomplishments and issues Participate in stress management and after-action debriefings. Participate in other briefings and meetings as required. Documents/Tools Incident Action Plan HICS Form 204 Branch Assignment Sheet HICS Form 207 Incident Management Team Chart HICS Form 213 Incident Message Form HICS Form 214 Operational Log Hospital emergency operations plan Hospital organization chart Hospital telephone directory Radio/satellite phone Facility blueprints and maps PC with internet access, as available Business continuity plans with contact information Section VII: Page 41 of 138

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129 PLANNING SECTION CHIEF Mission: Oversee all incident-related data gathering and analysis regarding incident operations and assigned resources, develop alternatives for tactical operations, conduct planning meetings, and prepare the Incident Action Plan (IAP) for each operational period. Date: Start: End: Position Assigned to: Initial: Position Reports to: Incident Commander Signature: Hospital Command Center (HCC) Location: Telephone: Fax: Other Contact Info: Radio Title: Immediate (Operational Period 0-2 Hours) Time Initial Receive appointment and briefing from the Incident Commander. Obtain packet containing Planning Section Job Action Sheets. Read this entire Job Action Sheet and review incident management team chart (HICS Form 207). Put on position identification. Notify your usual supervisor of your HICS assignment. Determine need for and appropriately appoint Unit Leaders, distribute corresponding Job Action Sheets and position identification. Complete the Branch Assignment List (HICS Form 204). Brief Planning Section Unit Leaders and Managers on current situation and incident objectives; develop response strategy and tactics; outline Section action plan and designate time for next briefing. Distribute the Section Personnel Time Sheet (HICS Form 252) to Planning Section personnel and ensure time is recorded appropriately. Submit the Section Personnel Time Sheet to the Finance/Administration Section s Time Unit Leader at the completion of a shift or at the end of each operational period. In consultation with the Incident Commander, establish the incident objectives and operational period. Initiate the Incident Objectives Form (HICS Form 202) and distribute to all activated HCC positions. Document all key activities, actions, and decisions in an Operational Log (HICS Form 214) on a continual basis. Establish and maintain communications with Logistics Section Chief and Staging Manager to ensure the accurate tracking of personnel and resources by the Personal Tracking and Materiel Tracking Managers. Facilitate and conduct incident action planning meetings with Command Staff, Section Chiefs and other key positions to plan for the next operational period. Coordinate preparation and documentation of the Incident Action Plan and distribute copies to the Incident Commander and all Section Chiefs. Ensure the Situation Unit Leader and staff regularly update and document status reports from all Section Chiefs and Unit Leaders. Ensure Planning Section personnel comply with safety policies and procedures. Document all communications (internal and external) on an Incident Message Form (HICS Form 213). Provide a copy of the Incident Message Form to the Documentation Unit. Intermediate (Operational Period 2-12 Hours) Time Initial Meet regularly with the Incident Commander to brief on the status of the Planning Section and the Incident Action Plan. Section VII: Page 42 of 138

130 Intermediate (Operational Period 2-12 Hours) Time Initial Initiate the Resource Accounting Record (HICS Form 257) to track equipment used during the response. Attend command briefings and meetings. Continue to conduct regular planning meetings with Planning Section Unit Leaders, Section Chiefs, Command Staff, and the Incident Commander for continued update and development of the Incident Action Plan. Ensure that the Planning Section is adequately staffed and supplied. Extended (Operational Period Beyond 12 Hours) Time Initial Continue to monitor Planning Section personnel s ability to meet workload demands, staff health and safety, resource needs, and documentation practices. Conduct regular situation briefings with Planning Section. Continue to receive projected activity reports from Section Chiefs and Planning Section Unit Leaders at designated intervals to prepare HCC status reports and update the Incident Action Plan. Continue to maintain the Resource Accounting Record (HICS Form 257) to track equipment used during the response. Ensure the Demobilization Unit Leader assesses ability to deactivate positions, as appropriate, in collaboration with Section Chiefs and develops and implements a demobilization plan. Ensure the Documentation Unit Leader is receiving and organizing all HCC documentation, including Operational Logs (HICS Form 214) and Incident Message Forms (HICS Form 213). Ensure your physical readiness through proper nutrition, water intake, rest, and stress management techniques. Observe all staff and volunteers for signs of stress and inappropriate behavior. Report concerns to the Employee Health & Well-Being Unit. Provide for staff rest periods and relief. Upon shift change, brief your replacement on the status of all ongoing operations, issues, and other relevant incident information. Demobilization/System Recovery Time Initial As needs decrease, return Planning Section staff to their usual jobs and combine or deactivate positions in a phased manner. Continue to meet with Command Staff, Section Chiefs and Planning Section Unit Leaders to evaluate facility and personnel, review the demobilization plan and update the Incident Action Plan. Ensure collection of all HCC documentation and Operational logs from Command and Sections as positions are deactivated and sections demobilized. Assist Section Chiefs in restoring hospital to normal operations. Coordinate final reporting of patient information with external agencies through Liaison Officer and Public Information Officer. Work with Planning and Finance/Administration Sections to complete cost data information. Begin development of the Incident After-Action Report and Improvement Plan and assign staff to complete portions/sections of the report. Debrief staff on lessons learned and procedural/equipment changes needed. Section VII: Page 43 of 138

131 Demobilization/System Recovery Time Initial Upon deactivation of your position, ensure all documentation and Operational Logs (HICS Form 214) are submitted to the Documentation Unit. Upon deactivation, brief the Incident Commander on current problems, outstanding issues, and follow-up requirements. Submit comments to the Incident Commander for discussion and possible inclusion in an after-action report; topics include: Review of pertinent position descriptions and operational checklists Recommendations for procedure changes Section accomplishments and issues Participate in stress management and after-action debriefings. Participate in other briefings and meetings as required. Documents/Tools Hospital Emergency Operations Plan Incident Action Plan HICS Form 202 Incident Objectives Form HICS Form 204 Branch Assignment List HICS Form 207 Incident Management Team Chart HICS Form 213 Incident Message Form HICS Form 214 Operational Log HICS Form 257 Resource Accounting Record HICS Form 254 Disaster Victim/Patient Tracking Form HICS Form 252 Section Personnel Time Sheet HICS Form 257 Resource Accounting Record Hospital organization chart Hospital telephone directory Radio/satellite phone Section VII: Page 44 of 138

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133 RESOURCES UNIT LEADER Mission: Maintain information on the status, location, and availability of personnel, teams, facilities, supplies, and major equipment to ensure availability of use during the incident. Maintain a master list of all resources assigned to incident operations. Date: Start: End: Position Assigned to: Initial: Position Reports to: Planning Section Chief Signature: Hospital Command Center (HCC) Location: Telephone: Fax: Other Contact Info: Radio Title: Immediate (Operational Period 0-2 Hours) Time Initial Receive appointment and briefing from the Planning Section Chief. Obtain packet containing Resources Unit Job Action Sheets. Read this entire Job Action Sheet and review incident management team chart (HICS Form 207). Put on position identification. Notify your usual supervisor of your HICS assignment. Appoint Managers as appropriate; distribute corresponding Job Action Sheets and position identification. Complete Branch Assignment Sheet (HICS Form 204) Personnel Tracking Manager Materiel Tracking Manager Brief Resources Unit Managers on current situation; outline team action plan and designate time for next briefing. Complete the Organization Assignment List (HICS Form 203) and distribute to all HCC staff. Consider posting a large size copy of the List in the HCC for reference and information. Document all key activities, actions, and decisions in an Operational Log (HICS Form 214). Establish contact with the Situation Unit Leader and hospital department heads to account for on-duty personnel, and equipment and supplies on hand. Coordinate activities and inventories with Logistics Section s Supply Unit Leader. Maintain contact and share information with Labor Pool & Credentialing Unit Leader and Personnel Staging Team Leader. Initiate Resource Accounting Record (HICS Form 257). Document all communications (internal and external) on an Incident Message Form (HICS Form 213). Provide a copy of the Incident Message Form to the Documentation Unit. Intermediate (Operational Period 2-12 Hours) Time Initial Meet regularly with the Planning Section Chief for status reports, and relay important information to Team Members. Meet with the Public Information Officer, Liaison Officer, Situation Unit Leader, Service Branch Director, and Support Branch Director as necessary to update and maintain resources tracking. Maintain and continually update the Resource Accounting Record (HICS Form 257) and normal resource Section VII: Page 45 of 138

134 Intermediate (Operational Period 2-12 Hours) Time Initial tracking systems (if available). Develop and submit an action plan to the Planning Section Chief when requested. Advise the Planning Chief immediately of any operational issue you are not able to correct or resolve. Coordinate personnel resource needs with the Labor Pool & Credentialing Unit Leader, Staging Manager. Extended (Operational Period Beyond 12 Hours) Time Initial Continue to monitor the Unit s ability to meet workload demands, staff health and safety, resource needs, and documentation practices. Continue to document actions and decisions on an Operational Log (HICS Form 214) and send to the Planning Section Chief at assigned intervals and as needed. Ensure your physical readiness through proper nutrition, water intake, rest, and stress management techniques. Observe all staff and volunteers for signs of stress and inappropriate behavior. Report concerns to the Employee Health & Well-Being Unit Leader. Provide for staff rest periods and relief. Upon shift change, brief your replacement on the status of all ongoing operations, issues, and other relevant incident information. Demobilization/System Recovery Time Initial As needs for Resources Unit staff decrease, return staff to their usual jobs and combine or deactivate positions in a phased manner. If IT systems were offline during the response, assure appropriate information from HICS Resource Accounting Record is transferred into the normal tracking systems. Debrief staff on lessons learned and procedural/equipment changes needed. Upon deactivation of your position, ensure all documentation and Operational Logs (HICS Form 214) are submitted to the Planning Section Chief or Documentation Unit, as appropriate. Upon deactivation of your position, brief the Planning Section Chief on current problems, outstanding issues, and follow-up requirements. Submit comments to the Planning Section Chief for discussion and possible inclusion in the after-action report; topics include: Review of pertinent position descriptions and operational checklists Recommendations for procedure changes Section accomplishments and issues Participate in stress management and after-action debriefings. Participate in other briefings and meetings as required. Section VII: Page 46 of 138

135 Documents/Tools Incident Action Plan HICS Form 204 Branch Assignment List HICS Form 207 Incident Management Team Chart HICS Form 213 Incident Message Form HICS Form 214 Operational Log HICS Form 257 Resource Accounting Record Hospital emergency operations plan Hospital organization chart Hospital telephone directory Radio/satellite phone IT systems, specially personnel, equipment, and supply tracking systems Section VII: Page 47 of 138

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137 SITUATION UNIT LEADER Mission: Collect, process, and organize ongoing situation information; prepare situation summaries; and develop projections and forecasts of future events related to the incident. Prepare maps and gather and disseminate information and intelligence for use in the Incident Action Plan (IAP). Date: Start: End: Position Assigned to: Initial: Position Reports to: Planning Section Chief Signature: Hospital Command Center (HCC) Location: Telephone: Fax: Other Contact Info: Radio Title: Immediate (Operational Period 0-2 Hours) Time Initial Receive appointment and briefing from the Planning Section Chief. Obtain packet containing Situation Unit Job Action Sheets. Read this entire Job Action Sheet and review incident management team chart (HICS Form 207). Put on position identification. Notify your usual supervisor of your HICS assignment. Appoint Managers as appropriate and complete the Branch Assignment List (HICS Form 204); distribute corresponding Job Action Sheets and identification. Patient Tracking Manager Bed Tracking Manager Obtain status report on Information Technology/Information systems. Establish a Planning information center in the HCC with a status/condition board and post information as it is received. Assign a recorder/documentation aide to keep the board updated with current information. Receive and record status reports as they are received. Assign a recorder to monitor, document and organize all communications sent and received via the interhospital emergency communication network or other external communication. Assure the status updates and information provided to Command Staff and Section Chiefs is accurate, complete, and current. Document all key activities, actions, and decisions in an Operational Log (HICS Form 214). Document all communications (internal and external) on an Incident Message Form (HICS Form 213). Provide a copy of the Incident Message Form to the Documentation Unit. Intermediate (Operational Period 2-12 Hours) Time Initial Meet regularly with the Planning Section Chief, Section Chiefs and Branch Directors to obtain situation and status reports, and relay important information to team Members. Ensure that an adequate number of recorders are assigned to perform Situation Unit activities. Coordinate personnel requests with Labor Pool & Credentialing Unit Leader. Ensure backup and protection of existing data for main and support computer systems, in coordination with Logistics Section s IT/IS Unit and Business Continuity Branch s Information Technology Unit. Publish an internal incident situation status report for employee information at least every 4 hours as Section VII: Page 48 of 138

138 Intermediate (Operational Period 2-12 Hours) Time Initial indicated. Collaborate with the Public Information Officer, Support Branch Director, and Labor Pool & Credentialing Unit Leader to develop and distribute the internal incident situation report. Ensure the security and prevent the loss of written and electronic HCC response documentation. Collaborate with the Security Officer and IT/IS Unit Leader as appropriate. Ensure development of a demobilization plan by the Demobilization Unit Leader, in collaboration with Section Chiefs and Command Staff. Assist the Planning Section Chief to develop the Incident Action Plan at designated intervals. Advise the Planning Section Chief immediately of any operational issue you are not able to correct or resolve. Extended (Operational Period Beyond 12 Hours) Time Initial Continue to monitor the Situation Unit staff s ability to meet workload demands, staff health and safety, resource needs, and documentation practices. Ensure your physical readiness through proper nutrition, water intake, rest, and stress management techniques. Observe all staff and volunteers for signs of stress and inappropriate behavior. Report concerns to appropriate Employee Health & Well Being Unit Leader. Provide for staff rest periods and relief. Upon shift change, brief your replacement on the status of all ongoing operations, issues, and other relevant incident information. Demobilization/System Recovery Time Initial As needs for the Situation Unit staff decrease, return staff to their usual jobs and combine or deactivate positions in a phased manner. Continue to revise and implement demobilization plan for all Sections. Compile incident summary data and reports, organize all HCC documentation and submit to Planning Section Chief. Assist with development of the incident After-Action Report and improvement plan. Debrief staff on lessons learned and procedural/equipment changes needed. Upon deactivation of your position, ensure all documentation and Operational Logs (HICS Form 214) are submitted to the Planning Section Chief. Upon deactivation of your position, ensure all documentation and Operational Logs (HICS Form 214) are submitted to the Planning Section Chief. Submit comments to the Planning Section Chief for discussion and possible inclusion in the after-action report; topics include: Review of pertinent position descriptions and operational checklists Recommendations for procedure changes Section accomplishments and issues Participate in stress management and after-action debriefings. Participate in other briefings and meetings as required. Section VII: Page 49 of 138

139 Documents/Tools Incident Action Plan HICS Form 204 Branch Assignment List HICS Form 207 Incident Management Team Chart HICS Form 213 Incident Message Form HICS Form 214 Operational Log Hospital emergency operations plan Hospital organization chart Hospital telephone directory Radio/satellite phone Access to IT systems ( , internet, telecommunications, printers) Chart-size facility plans and local area maps Section VII: Page 50 of 138

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141 DOCUMENTATION UNIT LEADER Mission: Maintain accurate and complete incident files, including a record of the hospital s/hcc s response and recovery actions and decisions; provide duplication services to incident personnel; and file, maintain, and store incident files for legal, analytical, and historical purposes. Date: Start: End: Position Assigned to: Initial: Position Reports to: Planning Section Chief Signature: Hospital Command Center (HCC) Location: Telephone: Fax: Other Contact Info: Radio Title: Immediate (Operational Period 0-2 Hours) Time Initial Receive appointment and briefing from the Planning Section Chief. Read this entire Job Action Sheet and review incident management team chart (HICS Form 207). Put on position identification. Notify your usual supervisor of your HICS assignment. Establish initial contact with all Section Chiefs to obtain status and history of all major events and actions that have occurred to date, critical issues, and concepts of operations and steps to be taken within the next operational period. Appoint team members as needed and complete the Branch Assignment List (HICS Form 204). Coordinate with IT/IS Unit to ensure access to IT systems with /intranet communication to increase communication and document sharing with all Sections (if available). Prepare a system to receive documentation and completed forms from all Sections over the course of the HCC activation. Provide duplicates of forms and reports to authorized HCC requestors. Prepare incident documentation for the Planning Section Chief when requested. Document all key activities, actions, and decisions in an Operational Log (HICS Form 214). Document all communications (internal and external) on an Incident Message Form (HICS Form 213). Provide a copy of the Incident Message Form to the Documentation Unit. Intermediate (Operational Period 2-12 Hours) Time Initial Regularly meet with all Section Chiefs regarding incident and Section status, steps taken to resolve critical issues, and projected actions and needs for the next operational period. Continue to accept and organize all documentation and forms submitted to the Documentation Unit. Check the accuracy and completeness of records submitted. Correct errors or omissions by contacting appropriate HCC Section staff. Maintain all historical information and record consolidated plans. Extended (Operational Period Beyond 12 Hours) Time Initial Section VII: Page 51 of 138

142 Extended (Operational Period Beyond 12 Hours) Time Initial Continue to meet regularly with the Planning Section Chief for status reports. Ensure your physical readiness through proper nutrition, water intake, rest, and stress management techniques. Observe all staff and volunteers for signs of stress and inappropriate behavior. Report concerns to appropriate Employee Health & Well Being Unit Leader. Provide for staff rest periods and relief. Upon shift change, brief your replacement on the status of all ongoing operations, issues, and other relevant incident information. Demobilization/System Recovery Time Initial As needs for the Documentation Unit staff decrease, return staff to their usual jobs and combine or deactivate positions in a phased manner. Ensure all documentation from HCC Command Staff and Sections is received and compiled. Upon deactivation of your position, ensure all documentation and Operational Logs (HICS Form 214) are submitted to the Planning Section Chief. Upon deactivation of your position, brief the Planning Chief on current problems, outstanding issues, and follow-up requirements. Submit comments to the Planning Section Chief for discussion and possible inclusion in the after-action report; topics include: Review of pertinent position descriptions and operational checklists Recommendations for procedure changes Section accomplishments and issues Participate in stress management and after-action debriefings. Participate in other briefings and meetings as required. Documents/Tools Incident Action Plan HICS Form 204 Branch Assignment List HICS Form 207 Incident Management Team Chart HICS Form 213 Incident Message Form HICS Form 214 Operational Log Hospital emergency operations plan Hospital organization chart Hospital telephone directory Radio/satellite phone Access to appropriate IT systems Section VII: Page 52 of 138

143 DEMOBILIZATION UNIT LEADER Mission: Develop and coordinate an Incident Demobilization Plan that includes specific instructions for all staff and resources that will require demobilization. Date: Start: End: Position Assigned to: Initial: Position Reports to: Planning Section Chief Signature: Hospital Command Center (HCC) Location: Telephone: Fax: Other Contact Info: Radio Title: Immediate (Operational Period 0-2 Hours) Time Initial Receive appointment and briefing from the Planning Section Chief. Read this entire Job Action Sheet and review incident management team chart (HICS Form 207). Put on position identification. Notify your usual supervisor of your HICS assignment. Establish initial contact with all Section Chiefs to obtain status of events and begin discussions about resources and personnel can be demobilized and when. Document all key activities, actions, and decisions in an Operational Log (HICS Form 214) on a continual basis. Document all communications (internal and external) on an Incident Message Form (HICS Form 213). Provide a copy of the Incident Message Form to the Documentation Unit. Intermediate (Operational Period 2-12 Hours) Time Initial Monitor incident response activities and needs. Regularly meet with all Section Chiefs and staff to maintain information regarding changes in their resource needs. Attend Incident Action Planning meetings and briefings. Continually update a consolidated Incident demobilization plan until a final version is prepared for approval. Extended (Operational Period Beyond 12 Hours) Time Initial Continue to meet regularly with the Planning Section Chief for status reports. Continue to assess the status of the incident and recommend deactivation of positions and personnel as the magnitude of the incident decreases. Ensure your physical readiness through proper nutrition, water intake, rest, and stress management techniques. Observe all staff and volunteers for signs of stress and inappropriate behavior. Report concerns to appropriate Employee Health & Well Being Unit Leader. Provide for staff rest periods and relief. Upon shift change, brief your replacement on the status of all ongoing operations, issues, and other relevant incident information. Section VII: Page 53 of 138

144 Demobilization/System Recovery Time Initial Continue to assess the status of the incident and recommend to Section Chiefs and Command the deactivation of positions and personnel as the magnitude of the incident decreases. Submit incident demobilization plan(s) to the Planning Section Chief for approval. Upon approval, distribute copies to all Section Chiefs. Upon deactivation of your position, ensure all documentation and Operational Logs (HICS Form 214) are submitted to the Planning Section Chief. Upon deactivation, brief the Planning Section Chief on current problems, outstanding issues, and follow-up requirements. Submit comments to the Planning Section Chief for discussion and possible inclusion in the after-action report; topics include: Review of pertinent position descriptions and operational checklists Recommendations for procedure changes Section accomplishments and issues Participate in stress management and after-action debriefings. Participate in other briefings and meetings as required. Documents/Tools Incident Action Plan HICS Form 207 Incident Management Team Chart HICS Form 213 Incident Message Form HICS Form 214 Operational Log Hospital emergency operations plan Hospital organization chart Hospital telephone directory Radio/satellite phone Section VII: Page 54 of 138

145 LOGISTICS SECTION CHIEF Mission: Organize and direct those operations associated with maintenance of the physical environment and with the provision of human resources, materiel, and services to support the incident activities. Participate in Incident Action Planning. Date: Start: End: Position Assigned to: Initial: Position Reports to: Incident Commander Signature: Hospital Command Center (HCC) Location: Telephone: Fax: Other Contact Info: Radio Title: Immediate (Operational Period 0-2 Hours) Time Initial Receive appointment and briefing from the Incident Commander. Obtain packet containing Logistics Section Job Action Sheets. Notify your usual supervisor of your HICS assignment. Read this entire Job Action Sheet and review incident management team chart (HICS Form 207). Put on position identification. Determine need to appoint Branch Directors and Unit Leaders in Logistics Section; distribute corresponding Job Action Sheets and position identification. Complete the Branch Assignment List (HICS Form 204). Brief Logistics Section Branch Directors on current situation, incident objectives and strategy; outline Section action plan and designate time for next briefing. Distribute the Section Personnel Time Sheet (HICS Form 252) to Logistic Section personnel and ensure time is recorded appropriately. Submit the Section Personnel Time Sheet to the Finance/Administration Section s Time Unit Leader at the completion of a shift or at the end of each operational period. Participate in Incident Action Plan preparation, briefings, and meetings as needed; assist in identifying strategies; determine tactics, work assignments, and resource requirements. Maintain communications with Operations Section Chief, Staging Manager and Branch Directors to assess critical issues and resource needs. Ensure resource ordering procedures are communicated to appropriate Sections and requests are timely and accurately processed. Ensure Logistics Section personnel comply with safety policies and procedures. Document all key activities, actions, and decisions in an Operational Log (HICS Form 214) on a continual basis. Document all communications (internal and external) on an Incident Message Form (HICS Form 213). Provide a copy of the Incident Message Form to the Documentation Unit. Intermediate (Operational Period 2-12 Hours) Time Initial Meet regularly with the Incident Commander, Command Staff and other Section Chiefs to update status of the response and relay important information to Logistics Section s Staff. Ensure the following are being addressed: Communications Information technology/information services Section VII: Page 55 of 138

146 Intermediate (Operational Period 2-12 Hours) Time Initial Provision of food and water for staff Employee health and well-being Family care Provision of supplies Facility maintenance Transportation services Establishment of Labor Pool Credentialing of staff and volunteers Documentation Initiate the Resource Accounting Record (HICS Form 257) to track equipment used during the response. Obtain needed materiel and fulfill resource requests with the assistance of the Finance/Administration Section Chief and Liaison Officer. Ensure that the Logistics Section is adequately staffed and supplied. Extended (Operational Period Beyond 12 Hours) Time Initial Continue to monitor Logistics Section staff s ability to meet workload demands, staff health and safety, resource needs, and documentation practices. Continue to conduct regular situation briefings with Logistics Section. Continue to document actions and decisions on an Operational Log (HICS Form 214) and on an Incident Message Form (HICS Form 213). Continue to maintain the Resource Accounting Record (HICS Form 257) to track equipment used during the response. Continue to meet regularly with Logistics Section Branch Directors to update the Section action plan and implement demobilization procedures, in coordination with Planning Section s Demobilization Unit Leader. Ensure your physical readiness through proper nutrition, water intake, rest, and stress management techniques. Observe all staff and volunteers for signs of stress and inappropriate behavior. Report concerns to the Employee Health & Well-Being Unit. Provide for staff rest periods and relief. Upon shift change, brief your replacement on the status of all ongoing operations, issues, and other relevant incident information. Demobilization/System Recovery Time Initial As needs decrease, return Logistics Section staff to their usual jobs and combine or deactivate positions in a phased manner. Coordinate return of all assigned equipment to appropriate locations and restock HCC supplies. Ensure return/retrieval of equipment and supplies and return all assigned incident command equipment. Coordinate replacement of broken or misplaced items. Work with Planning and Finance/Administration Sections to complete cost data information. Debrief Section staff on lessons learned and procedural/equipment changes needed. Upon deactivation of your position, ensure all documentation and Operational Logs (HICS Form 214) are submitted to the Incident Commander. Section VII: Page 56 of 138

147 Demobilization/System Recovery Time Initial Upon deactivation of your position, brief the Incident Commander on current problems, outstanding issues, and follow-up requirements. Submit comments to the Planning Section Chief for discussion and possible inclusion in an after-action report; topics include: Review of pertinent position descriptions and operational checklists Recommendations for procedure changes Section accomplishments and issues Participate in stress management and after-action debriefings. Participate in other briefings and meetings as required. Documents/Tools Incident Action Plan HICS Form 204 Branch Assignment Sheet HICS Form 207 Incident Management Team Chart HICS Form 213 Incident Message Form HICS Form 214 Operational Log HICS Form 252 Section Personnel Time Sheet HICS Form 257 Resource Tracking Record Hospital emergency operations plan Hospital organization chart Hospital telephone directory Radio/satellite phone Master inventory control lists Section VII: Page 57 of 138

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149 SERVICE BRANCH DIRECTOR Mission: Organize and manage the services required to maintain the hospital s communication system, food and water supply for staff, and information technology and systems. Date: Start: End: Position Assigned to: Initial: Position Reports to: Logistics Section Chief Signature: Hospital Command Center (HCC) Location: Telephone: Fax: Other Contact Info: Radio Title: Immediate (Operational Period 0-2 Hours) Time Initial Receive appointment and briefing from the Logistics Section Chief. Obtain packet containing Service Branch Job Action Sheets. Read this entire Job Action Sheet and review incident management team chart (HICS Form 207). Put on position identification. Notify your usual supervisor of your HICS assignment. Document all key activities, actions, and decisions in an Operational Log (HICS Form 214). Determine need for and appropriately appoint Logistics Section Service Branch Unit Leaders; distribute corresponding Job Action Sheets and position identification. Complete the Branch Assignment List (HICS Form 204). Brief the Service Branch Unit Leaders on current situation and incident objectives; outline Branch action plan and designate time for next briefing. Assess the Service Branch s capacity to deliver needed: Internal and external communication capability Information technology hardware, software and support Food and water for staff (Patient feeding is under Operations Section Infrastructure Branch) Meet regularly with the Logistics Section Chief to discuss status, plan of action, critical issues and staffing in Service Branch. Instruct Unit Leaders to: Immediately set-up the HCC communications and IT systems to ensure connectivity Evaluate on-hand communications equipment required for response and project need for repair and expanded inventory Inventory on-hand food and water supply Assess and evaluate IT/IS capability, and determine need for repair or expansion of service and support Inventory and assessment of communications equipment and project need for repair and expanded inventory Report inventories and needs to Logistics Section s Support Branch Supply Unit Leader Assess problems and needs in each Service Branch area; coordinate resource management. Ensure Service Branch personnel comply with safety policies and procedures. Document all communications (internal and external) on an Incident Message Form (HICS Form 213). Provide a copy of the Incident Message Form to the Documentation Unit. Section VII: Page 58 of 138

150 Intermediate (Operational Period 2-12 Hours) Time Initial Ensure prioritization of problems when multiple issues are presented. Continue coordinating the Service Branch s ability to provide needed communication and IT/IS support services. Coordinate use of external resources to assist with equipment, software and hardware maintenance and repairs. Advise Logistics Section Chief immediately of any operational issue you are not able to correct or resolve. Continue to meet regularly with the Logistics Section Chief for status reports and relay important information to Unit Leaders. Report equipment needs to Supply Unit Leader. Ensure staff health and safety issues are being addressed; resolve with the Logistics Section Chief, Safety Officer and Employee Health and Well-Being, as appropriate. Develop and submit a Branch action plan to Logistics Section Chief when requested. Extended (Operational Period Beyond 12 Hours) Time Initial Continue to monitor Service Branch staff s ability to meet workload demands, staff health and safety, resource needs, and documentation practices. Conduct regular situation briefings with the Service Branch Unit Leaders and update operational action plan as needed. Continue to meet with the Logistics Section Chief to update the Service Branch action plan and implement demobilization procedures. Continue to document actions and decisions on an Operational Log (HICS Form 214) and send to the Logistics Section Chief at assigned intervals and as needed. Ensure your physical readiness through proper nutrition, water intake, rest, and stress management techniques. Observe all staff and volunteers for signs of stress and inappropriate behavior. Report concerns to the Employee Health & Well-Being Unit Leader. Provide for staff rest periods and relief. Upon shift change, brief your replacement on the status of all ongoing operations, issues, and other relevant incident information. Demobilization/System Recovery Time Initial As needs for Service Branch staff decrease, return staff to their usual jobs and combine or deactivate positions in a phased manner. Assist the Logistics Section Chief and Unit Leaders with restoring hospital infrastructure services to normal operations. Ensure return/retrieval of equipment and supplies and return all assigned incident command equipment. Upon deactivation of your position, ensure all documentation and Operational Logs (HICS Form 214) are submitted to the Logistics Section Chief. Upon deactivation of your position, brief the Logistics Section Chief on current problems, outstanding issues, and follow-up requirements. Section VII: Page 59 of 138

151 Demobilization/System Recovery Time Initial Submit comments to the Logistics Section Chief for discussion and possible inclusion in the after-action report; topics include: Review of pertinent position descriptions and operational checklists Recommendations for procedure changes Section accomplishments and issues Participate in stress management and after-action debriefings. Participate in other briefings and meetings as required. Documents/Tools Incident Action Plan HICS Form 204 Branch Assignment List HICS Form 207 Incident Management Team Chart HICS Form 213 Incident Message Form HICS Form 214 Operational Log Hospital emergency operations plan Hospital organization chart Hospital telephone directory Radio/satellite phone Facility maps and ancillary services schematics Vendor support and repair directory Section VII: Page 60 of 138

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153 SUPPORT BRANCH DIRECTOR Mission: Organize and manage the services required to maintain the hospital s supplies, facilities, transportation, and labor pool. Ensure the provision of logistical, psychological, and medical support of hospital staff and their dependents. Date: Start: End: Position Assigned to: Initial: Position Reports to: Logistics Section Chief Signature: Hospital Command Center (HCC) Location: Telephone: Fax: Other Contact Info: Radio Title: Immediate (Operational Period 0-2 Hours) Time Initial Receive appointment and briefing from the Logistics Section Chief. Obtain packet containing Support Branch Job Action Sheets. Read this entire Job Action Sheet and review incident management team chart (HICS Form 207). Put on position identification. Notify your usual supervisor of your HICS assignment. Document all key activities, actions and decisions in an Operational Log (HICS Form 214). Determine need for and appropriately appoint Unit Leaders; distribute corresponding Job Action Sheets and position identification. Complete the Branch Assignment List (HICS Form 204). Brief the Support Branch Unit Leaders on current situation and incident objectives; outline Branch action plan and designate time for next briefing. Assess Support Branch areas capacity to deliver needed: Employee health care Mental health support to staff Family support to staff Medical equipment and supplies Facility cleanliness Internal and external transportation support Supplemental personnel management Complete the Staff Medical Plan (HICS Form 206) and distribute to Command Staff, Section Chiefs and Documentation Unit Leader. In collaboration with the Safety Officer and the Operations Section s HazMat Branch Director, determine need for staff personal protective equipment; implement protective actions as required. Regularly report Service Branch status to the Logistics Section Chief. Instruct all Unit Leaders to evaluate on-hand equipment, supply, and medication inventories and staff needs; report status to the Supply Unit Leader. Assess mental health status concerns and; determine need for expanded support. Coordinate activities with the Operations Section s Mental Health Unit Leader. Assess problems and needs in each Unit area; coordinate resource management. Meet with the Logistics Section Chief to discuss plan of action and staffing in all Support Branch activities. Section VII: Page 61 of 138

154 Immediate (Operational Period 0-2 Hours) Time Initial Receive, coordinate and forward requests for personnel to the Labor Pool and Credentialing Unit Leader and supplies to the Supply Unit Leader. Document all communications (internal and external) on an Incident Message Form (HICS Form 213). Provide a copy of the Incident Message Form to the Documentation Unit. Intermediate (Operational Period 2-12 Hours) Time Initial Continue assessing and coordinating Support Branch s ability to provide needed personnel and support services. Ensure prioritization of problems when multiple issues are presented Continue to evaluate the need for staff personal protection measures, in coordination with the Safety Officer and Operations Section s HazMat Branch Director and implement actions as indicated. Update and revise the Staff Medical Plan (HICS Form 206) and distribute to Command Staff, Section Chiefs and Documentation Unit Leader. Assign mental health personnel to visit patient care areas and evaluate staff needs; in coordination with the Operations Section s Mental Health Unit Leader and report issues to the Logistics Section Chief. Implement dependent care service support per the Emergency Management Plan. Coordinate use of external resources to assist with service delivery. Advise the Logistics Section Chief immediately of any operational issue you are not able to correct or resolve. Meet routinely with the Logistics Section Chief for status reports, and relay important information to staff. Assess environmental services (housekeeping) needs in all staff activity areas. Report equipment needs to the Supply Unit Leader. Supervise salvage operations with the Operations Section Chief when indicated. Ensure staff health and safety issues being addressed; resolve with the Safety Officer when appropriate. Develop and submit a branch action plan to the Logistics Section Chief when requested. Extended (Operational Period Beyond 12 Hours) Time Initial Continue to monitor Support Branch staff s ability to meet workload demands, staff health and safety, resource needs, and documentation practices. Continue to document actions and decisions on an Operational Log (HICS Form 214) and send to the Support Branch Director at assigned intervals and as needed. Coordinate support to sick/injured staff. Collaborate and communicate with the Finance/Administration Section Compensation/Claims Unit Leader. Coordinate staff line of duty death response plan. Expand dependent care capacity as situation warrants and resources allow. Continue to provide Logistics Section Chief with periodic situational updates. Assess staff medical health status regularly; note absenteeism trends and investigate; report findings and recommendations to the Logistics Section Chief and Employee Health and Well-Being Unit. Section VII: Page 62 of 138

155 Extended (Operational Period Beyond 12 Hours) Time Initial Provide continuing mental health information and assistance for staff as needed; coordinate pastoral care and solicited volunteer s assistance, in coordination with Operations Section s Mental Health Unit Leader; update the Logistics Section Chief. Ensure your physical readiness through proper nutrition, water intake, rest, and stress management techniques. Observe all staff and volunteers for signs of stress and inappropriate behavior. Report concerns to the Employee Health & Well-Being Unit Leader. Provide for staff rest periods and relief. Upon shift change, brief your replacement on the status of all ongoing operations, issues, and other relevant incident information. Demobilization/System Recovery Time Initial As needs for Support Branch staff decrease, return staff to their usual jobs and combine or deactivate positions in a phased manner. Assist the Logistics Section Chief and Unit Leaders with addressing staff health and medical concerns. Assist the Logistics Section Chief and Unit Leaders with returning Support Branch operations to normal. Ensure return/retrieval of equipment and supplies and return all assigned incident command equipment. Upon deactivation of your position, ensure all documentation and Operational Logs (HICS Form 214) are submitted to the Logistics Section Chief. Upon deactivation of your position, brief the Logistics Section Chief on current problems, outstanding issues, and follow-up requirements. Submit comments to the Logistics Section Chief for discussion and possible inclusion in the after-action report; topics include: Review of pertinent position descriptions and operational checklists Recommendations for procedure changes Section accomplishments and issues Participate in stress management and after-action debriefings. Participate in other briefings and meetings as required. Documents/Tools Incident Action Plan HICS Form 204 Branch Assignment List HICS Form 206 Staff Medical Plan HICS Form 207 Incident Management Team Chart HICS Form 213 Incident Message Form HICS Form 214 Operational Log Hospital emergency operations plan Hospital organization chart Hospital telephone directory Radio/satellite phone Facility maps and ancillary services schematics Vendor support and repair directory Section VII: Page 63 of 138

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157 FINANCE/ADMINISTRATION SECTION CHIEF Mission: Monitor the utilization of financial assets and the accounting for financial expenditures. Supervise the documentation of expenditures and cost reimbursement activities. Date: Start: End: Position Assigned to: Initial: Position Reports to: Incident Commander Signature: Hospital Command Center (HCC) Location: Telephone: Fax: Other Contact Info: Radio Title: Immediate (Operational Period 0-2 Hours) Time Initial Receive appointment and briefing from the Incident Commander. Obtain packet containing Finance/Administration Section Job Action Sheets. Notify your usual supervisor of your HICS assignment. Read this entire Job Action Sheet and review incident management team chart (HICS Form 207). Put on position identification. Determine need for and appropriately appoint Finance/Administration Unit Leaders, distribute corresponding Job Action Sheets and position identification. Complete the Branch Assignment List (HICS Form 204). Brief Finance/Administration Section Unit Leaders on current situation, incident objectives, and strategy; outline Section action plan; and designate time for next briefing. Participate in Incident Action Plan preparation, briefings, and meetings as needed and, Provide cost implications of incident objectives Ensure that the Incident Action Plan is within financial limits established by the Incident Commander Determine if any special contractual arrangements/agreements are needed. Obtain information and updates regularly from Finance/Administration Section Unit Leaders; maintain knowledge of current status of all Units; inform Situation Unit Leader of status information. Distribute the Section Personnel Time Sheet (HICS Form 252) to Finance/Administration Section staff and ensure time is recorded appropriately. Submit the Section Personnel Time Sheet to the Finance/Administration Section s Time Unit Leader at the completion of a shift or at the end of each operational period. Ensure Finance/Administration Section personnel comply with safety policies and procedures. Document all key activities, actions, and decisions on an Operational Log (HICS Form 214) on a continual basis. Document all communications (internal and external) on an Incident Message Form (HICS Form 213). Provide a copy of the Incident Message Form to the Documentation Unit. Intermediate (Operational Period 2-12 Hours) Time Initial Communicate frequently with the Incident Commander; brief routinely on the status of the Finance/Administration Section. Initiate the Resource Accounting Record (HICS Form 257) to track equipment used during the response. Designate times for briefings and updates with Finance/Administration Section Unit Leaders to develop or update the Section action plan. Approve a "cost-to-date" incident financial status report submitted by the Cost Unit Leader every eight hours Section VII: Page 64 of 138

158 Intermediate (Operational Period 2-12 Hours) Time Initial summarizing financial data relative to personnel, supplies and other expenditures and expenses. Work with the Incident Commander and other Section Chiefs to identify short and long term issues with financial implications; establish needed policies and procedures Ensure that the Finance/Administration Section is adequately staffed and supplied. Extended (Operational Period Beyond 12 Hours) Time Initial Continue to monitor Finance/Administration Section staff s ability to meet workload demands, staff health and safety, resource needs, and documentation practices. Conduct regular situation update briefings with Finance/Administration Section. Continue to maintain the Resource Accounting Record (HICS Form 257) to track equipment used during the response. Schedule planning meetings with Finance/Administration Section staff to update the Section action plan and demobilization procedures. Ensure that required financial and administrative documentation Is properly prepared. Collate and process invoices received. Present financial updates to the Incident Commander and Command Staff every 8 hours and as requested. Ensure that routine, non-incident related administrative oversight of hospital financial operations is maintained. Continue to document actions and decisions on an Operational Log (HICS Form 214). Coordinate emergency procurement requests with Supply Unit Leader. Maintain cash reserves on hand. Ensure automated teller machines (ATMs) located in the hospital (whether hospital- or other-owned are maintained and available to staff. Consult with local, state, and federal officials regarding reimbursement regulations and requirements; ensure required documentation is prepared according to guidance received. Ensure your physical readiness through proper nutrition, water intake, rest, and stress management techniques. Observe all staff and volunteers for signs of stress and inappropriate behavior. Report concerns to the Employee Health & Well-Being Unit. Provide for staff rest periods and relief. Upon shift change, brief your replacement on the status of all ongoing operations, issues, and other relevant incident information. Demobilization/System Recovery Time Initial As needs in the Finance/Administration Section decrease, return staff to their usual jobs and combine or deactivate positions in a phased manner. Collect and analyze all financial related data from Finance/Administration Section Units. Ensure processing and payment of invoiced costs. Submit required reimbursement paperwork and track payments. Debrief staff on lessons learned and procedural/equipment changes needed. Section VII: Page 65 of 138

159 Demobilization/System Recovery Time Initial Upon deactivation of your position, ensure all documentation and Operational Logs (HICS Form 214) are submitted to the Planning Section Chief. Upon deactivation of your position, brief the Incident Commander on current problems, outstanding issues, and follow-up requirements. Submit comments to the Incident Commander for discussion and possible inclusion in an after-action report; topics include: Review of pertinent position descriptions and operational checklists Recommendations for procedure changes Section accomplishments and issues Participate in stress management and after-action debriefings. Participate in other briefings and meetings as required. Documents/Tools Incident Action Plan HICS Form 204 Branch Assignment List HICS Form 207 Incident Management Team Chart HICS Form 213 Incident Message Form HICS Form 214 Operational Log HICS Form 252 Section Personnel Time Sheet HICS Form 257 Resource Accounting Record Hospital emergency operations plan Hospital organization chart Hospital telephone directory Radio/satellite phone Hospital inventory Hospital financial data forms State and DHS/FEMA reimbursement forms Section VII: Page 66 of 138

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161 TIME UNIT LEADER Mission: Responsible for the documentation of personnel time records. Monitor and report on regular and overtime hours worked/volunteered. Date: Start: End: Position Assigned to: Initials: Position Reports to: Finance/Administration Section Chief Signature: Hospital Command Center (HCC) Location: Telephone: Fax: Other Contact Info: Radio Title: Immediate (Operational Period 0-2 Hours) Time Initial Receive appointment, briefing, and any appropriate materials from the Finance/Administration Section Chief. Read this entire Job Action Sheet and review incident management team chart (HICS Form 207). Put on position identification. Notify your usual supervisor of your HICS assignment. Document all key activities, actions, and decisions in an Operational Log (HICS Form 214). Appoint Unit members and complete the Branch Assignment List (HICS Form 204). Brief Unit members on current situation, incident objectives, and strategy; outline Unit action plan; and designate time for next briefing. Ensure Unit members comply with safety policies and procedures. Ensure the documentation of personnel hours worked and volunteer hours worked in all areas relevant to the hospital's emergency incident response. Confirm the utilization of the Section Personnel Time Sheet (HICS Form 252) by all Section Chiefs and/or Unit Leaders. Coordinate with Labor Pool & Credentialing Unit Leader. Assist Personnel Tracking Manager in accounting for facility staff. Document all communications (internal and external) on an Incident Message Form (HICS Form 213). Provide a copy of the Incident Message Form to the Documentation Unit. Intermediate (Operational Period 2-12 Hours) Time Initial Meet routinely with the Finance/Administration Section Chief for status reports, and relay important information to Unit members. Collect all Section Personnel Time Sheets (HICS Form 252) from each work area for recording and tabulation every eight hours, or as specified by the Finance/Administration Section Chief. Forward tabulated Section Personnel Time Sheets (HICS Form 252) to the Cost Unit Leader every eight hours or as requested. Develop and submit an action plan to the Finance/Administration Section Chief when requested. Advise the Finance/Administration Section Chief immediately of any operational issue you are not able to correct or resolve. Section VII: Page 67 of 138

162 Extended (Operational Period Beyond 12 Hours) Time Initial Continue to provide a summary of staff and volunteer personnel hours worked during the incident every 8 hours and as requested. Forward tabulated Section Personnel Time Sheets (HICS Form 252) to the Cost Unit Leader every eight hours or as requested. Continue to document actions and decisions on an Operational Log (HICS Form 214) and send to the Finance/Administration Section Chief at assigned intervals and as needed. Ensure your physical readiness through proper nutrition, water intake, rest, and stress management techniques. Observe all staff and volunteers for signs of stress and inappropriate behavior. Report concerns to the Employee Health & Well-Being Unit Leader. Provide for staff rest periods and relief. Upon shift change, brief your replacement on the status of all ongoing operations, issues, and other relevant incident information. Demobilization/System Recovery Time Initial As needs for the Time Unit decrease, return staff to their usual jobs and combine or deactivate positions in a phased manner. Submit all Section Personnel Time Sheets to the Cost Unit Leader. Debrief staff on lessons learned and procedural/equipment changes needed. Upon deactivation of your position, ensure all documentation and Operational Logs (HICS Form 214) are submitted to the Finance/Administration Section Chief. Upon deactivation of your position, brief the Finance/Administration Section Chief on current problems, outstanding issues, and follow-up requirements. Submit comments to the Finance/Administration Section Chief for discussion and possible inclusion in the after-action report; topics include: Review of pertinent position descriptions and operational checklists Recommendations for procedure changes Section accomplishments and issues Participate in stress management and after-action debriefings. Participate in other briefings and meetings as required. Documents/Tools Incident Action Plan HICS Form 204 Branch Assignment Sheet HICS Form 207 Incident Management Team Chart HICS Form 213 Incident Message Form HICS Form 214 Operational Log HICS Form 252 Section Personnel Time Sheet Hospital emergency operations plan Hospital organization chart Hospital telephone directory Radio/satellite phone Standard timekeeping/payroll procedures Section VII: Page 68 of 138

163 PROCUREMENT UNIT LEADER Mission: Responsible for administering accounts receivable and payable to contract and non-contract vendors. Date: Start: End: Position Assigned to: lnitials: Position Reports to: Finance/Administration Section Chief Signature: Hospital Command Center (HCC) Location: Telephone: Fax: Other Contact Info: Radio Title: Immediate (Operational Period 0-2 Hours) Time Initial Receive appointment, briefing, and any appropriate materials from the Finance/Administration Section Chief. Read this entire Job Action Sheet and review incident management team chart (HICS Form 207). Put on position identification. Notify your usual supervisor of your HICS assignment. Document all key activities, actions, and decisions in an Operational Log (HICS Form 214). Appoint Unit members and complete the Branch Assignment List (HICS Form 204). Brief Unit members on current situation, incident objectives, and strategy; outline Unit action plan; and designate time for next briefing. Ensure Unit members comply with safety policies and procedures. Ensure the separate accounting of all contracts specifically related to the emergency incident and of all purchases within the enactment of the emergency incident management plan. Establish a line of communication with the Supply Unit Leader to insure resource coordination. Obtain authorization to initiate and finalize purchases from the Finance/Administration Section Chief, or authorized representative. Interpret and initiate contracts/agreements to minimize costs (when possible) and resolve disputes. Establish and document emergency agreements for the sharing, transfer of material, supplies, etc., to other entities. Document all communications (internal and external) on an Incident Message Form (HICS Form 213). Provide a copy of the Incident Message Form to the Documentation Unit. Intermediate (Operational Period 2-12 Hours) Time Initial Meet routinely with the Finance/Administration Section Chief for status reports, and relay important information to Unit members. Maintain log of all purchases related to the incident and initiate the Procurement Summary Report (HICS Form 256). Collect invoices and other records to reconcile them with the procurement agreements before forwarding them to the Cost Unit Leader. Forward a summary accounting of purchases on the Procurement Summary Report (HICS Form 256) to the Cost Unit Leader every eight hours, or as determined by the Cost Unit Leader. Section VII: Page 69 of 138

164 Intermediate (Operational Period 2-12 Hours) Time Initial Coordinate with the Supply Unit Leader to ensure that procurements meet the needs of the requestors. Develop and submit an action plan to the Finance/Administration Section Chief when requested. Advise the Finance/Administration Section Chief immediately of any operational issue you are not able to correct or resolve. Extended (Operational Period Beyond 12 Hours) Time Initial Continue to maintain the Procurement Summary Report (HICS Form 256), identifying all contracts initiated during the incident. Continue to document actions and decisions on an Operational Log (HICS Form 214) and send to the Finance/Administration Section Chief at assigned intervals and as needed. Ensure your physical readiness through proper nutrition, water intake, rest, and stress management techniques. Observe all staff and volunteers for signs of stress and inappropriate behavior. Report concerns to the Employee Health & Well-Being Unit Leader. Provide for staff rest periods and relief. Upon shift change, brief your replacement on the status of all ongoing operations, issues, and other relevant incident information. Demobilization/System Recovery Time Initial As needs for the Procurement Unit staff decrease, return staff to their usual jobs and combine or deactivate positions in a phased manner. Ensure complete closure of contracts, agreements, purchases, etc, relating to the emergency incident. Debrief staff on lessons learned and procedural/equipment changes needed. Upon deactivation of your position, ensure all documentation and Operational Logs (HICS Form 214) are submitted to the Finance/Administration Section Chief. Upon deactivation of your position, brief the Finance/Administration Section Chief on current problems, outstanding issues, and follow-up requirements. Submit comments to the Finance/Administration Section Chief for discussion and possible inclusion in the after-action report; topics include: Review of pertinent position descriptions and operational checklists Recommendations for procedure changes Section accomplishments and issues Participate in stress management and after-action debriefings. Participate in other briefings and meetings as required. Documents/Tools Incident Action Plan HICS Form 204 Branch Assignment List HICS Form 207 Incident Management Team Chart HICS Form 213 Incident Message Form HICS Form 214 Operational Log HICS Form 256 Procurement Summary Report Section VII: Page 70 of 138

165 Documents/Tools Hospital emergency operations plan Hospital organization chart Hospital telephone directory Radio/satellite phone Standard procurement protocol, including coding information Contract and non-contract vendor lists Section VII: Page 71 of 138

166

167 COMPENSATION/CLAIMS UNIT LEADER Mission: Responsible for receiving, investigating and documenting all claims reported to the hospital during the emergency incident, which are alleged to be the result of an accident or action on hospital property. Date: Start: End: Position Assigned to: Initials: Position Reports to: Finance/Administration Section Chief Signature: Hospital Command Center (HCC) Location: Telephone: Fax: Other Contact Info: Radio Title: Immediate (Operational Period 0-2 Hours) Time Initial Receive appointment, briefing, and any appropriate materials from the Finance/Administration Section Chief. Read this entire Job Action Sheet and review incident management team chart (HICS Form 207). Put on position identification. Notify your usual supervisor of your HICS assignment. Document all key activities, actions, and decisions in an Operational Log (HICS Form 214). Appoint Unit members and complete the Branch Assignment List (HICS Form 204). Brief Unit members on current situation, incident objectives, and strategy; outline Unit action plan; and designate time for next briefing. Ensure Unit members comply with safety policies and procedures. Receive, investigate and document claims issued by employees and non-employees. Use photographs or video documentation when appropriate. Obtain statements as quickly as possible from all claimants and witnesses. Enlist the assistance of the Safety Officer, Security Branch Director and Employee Health and Well-Being Unit Leader, as needed. Document all communications (internal and external) on an Incident Message Form (HICS Form 213). Provide a copy of the Incident Message Form to the Documentation Unit. Intermediate (Operational Period 2-12 Hours) Time Initial Meet routinely with the Finance/Administration Section Chief for status reports, and relay important information to Unit members. Inform the Finance/Administration Section Chief of all claims as they are reported. Document claims on hospital risk/loss forms. Coordinate with hospital Risk Management. Ensure that records required by insurers, government and other agencies for loss recovery are accurately compiled, maintained, and available. Develop and submit an action plan to the Finance/Administration Section Chief when requested. Advise the Finance/Administration Section Chief immediately of any operational issue you are not able to correct or resolve. Section VII: Page 72 of 138

168 Extended (Operational Period Beyond 12 Hours) Time Initial Report any cost incurred as a result of a claim to the Cost Unit Leader as soon as possible. Prepare a summary of all claims reported during the incident every 8 hours and as requested. Continue to document actions and decisions on an Operational Log (HICS Form 214) and send to the Finance/Administration Section Chief at assigned intervals and as needed. Ensure your physical readiness through proper nutrition, water intake, rest, and stress management techniques. Observe all staff and volunteers for signs of stress and inappropriate behavior. Report concerns to the Employee Health & Well-Being Leader. Provide for staff rest periods and relief. Upon shift change, brief your replacement on the status of all ongoing operations, issues, and other relevant incident information. Demobilization/System Recovery Time Initial As needs for the Compensation/Claims Unit staff decrease, return staff to their usual jobs and combine or deactivate positions in a phased manner. Compile final claims report(s) and submit to Finance/Administration Section Chief. Debrief staff on lessons learned and procedural/equipment changes needed. Upon deactivation of your position, ensure all documentation and Operational Logs (HICS Form 214) are submitted to the Finance/Administration Section Chief. Upon deactivation of your position, brief the Finance/Administration Section Chief on current problems, outstanding issues, and follow-up requirements. Submit comments to the Finance/Administration Section Chief for discussion and possible inclusion in the after-action report; topics include: Review of pertinent position descriptions and operational checklists Recommendations for procedure changes Section accomplishments and issues Participate in stress management and after-action debriefings. Participate in other briefings and meetings as required. Documents/Tools Incident Action Plan HICS Form 204 Branch Assignment List HICS Form 207 Incident Management Team Chart HICS Form 213 Incident Message Form HICS Form 214 Operational Log Hospital emergency operations plan Hospital organization chart Hospital telephone directory Radio/satellite phone Standard claims protocol/procedure Insurer information Relevant government protocols Section VII: Page 73 of 138

169 Documents/Tools Claims log form Section VII: Page 74 of 138

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171 COST UNIT LEADER Mission: Responsible for providing cost analysis data for the declared emergency incident and maintenance of accurate records of incident cost. Date: Start: End: Position Assigned to: Initial: Position Reports to: Finance/Administration Section Chief Signature: Hospital Command Center (HCC) Location: Telephone: Fax: Other Contact Info: Radio Title: Immediate (Operational Period 0-2 Hours) Time Initial Receive appointment, briefing, and any appropriate materials from the Finance/Administration Section Chief. Read this entire Job Action Sheet and review incident management team chart (HICS Form 207). Put on position identification. Notify your usual supervisor of your HICS assignment. Document all key activities, actions, and decisions in an Operational Log (HICS Form 214). Appoint Unit members and complete the Branch Assignment List (HICS Form 204). Brief Unit members on current situation, incident objectives, and strategy; outline Unit action plan; and designate time for next briefing. Ensure Unit members comply with safety policies and procedures. Establish cost reporting procedures, including proper coding. Implement third-party billing procedures. Implement procedures for receiving and depositing funds. Document all communications (internal and external) on an Incident Message Form (HICS Form 213). Provide a copy of the Incident Message Form to the Documentation Unit. Intermediate (Operational Period 2-12 Hours) Time Initial Meet routinely with the Finance/Administration Section Chief for status reports, and relay important information to Unit members. Maintain cost tracking and analysis. Collect copies, summaries, or original documentation of costs from all cost centers. Prepare a cost-to-date summary report for submission to the Finance/Administration Section Chief every eight hours and as requested. Inform Section Chiefs of pertinent cost data at the direction of the Finance/Administration Section Chief or Incident Commander. Develop and submit an action plan to the Finance/Administration Section Chief when requested. Advise the Finance/Administration Section Chief immediately of any operational issue you are not able to correct or resolve. Section VII: Page 75 of 138

172 Extended (Operational Period Beyond 12 Hours) Time Initial Continue to prepare a summary of all costs incurred during the incident every 8 hours and as requested. Continue to document actions and decisions on an Operational Log (HICS Form 214) and send to the Finance/Administration Section Chief at assigned intervals and as needed. Ensure your physical readiness through proper nutrition, water intake, rest, and stress management techniques. Observe all staff and volunteers for signs of stress and inappropriate behavior. Report concerns to the Employee Health & Well-Being Unit Leader. Provide for staff rest periods and relief. Upon shift change, brief your replacement on the status of all ongoing operations, issues, and other relevant incident information. Demobilization/System Recovery Time Initial As needs for the Cost Unit staff decrease, return staff to their usual jobs and combine or deactivate positions in a phased manner. Compile final cost accounting report(s) to Finance/Administration Section Chief. Debrief staff on lessons learned and procedural/equipment changes needed. Complete all cost records and prepare a report/summary of incident costs. Upon deactivation of your position, ensure all documentation and Operational Logs (HICS Form 214) are submitted to the Finance/Administration Section Chief. Upon deactivation of your position, brief the Finance/Administration Section Chief on current problems, outstanding issues, and follow-up requirements. Submit comments to the Finance/Administration Section Chief for discussion and possible inclusion in the after-action report; topics include: Review of pertinent position descriptions and operational checklists Recommendations for procedure changes Section accomplishments and issues Participate in stress management and after-action debriefings. Participate in other briefings and meetings as required. Documents/Tools Incident Action Plan HICS Form 204 Branch Assignment List HICS Form 207 Incident Management Team Chart HICS Form 213 Incident Message Form HICS Form 214 Operational Log Hospital emergency operations plan Hospital organization chart Hospital telephone directory Radio/satellite phone Standard cost accounting protocols/procedures Cost-to-date summary report form Section VII: Page 76 of 138

173 ACS / HICS FORMS APPENDIX C Section VII: Page 77 of 138

174 Section VII: Page 78 of 138

175 HICS 201 Purpose: Document Initial response information and actions taken at startup Origination: Incident Commander HICS 201 INCIDENT BRIEFING 1. INCIDENT NAME 2. DATE OF BRIEFING 3. TIME OF BRIEFING 4. EVENT HISTORY AND CURRENT ACTIONS SUMMARY 5. CURRENT ORGANIZATION Section VII: Page 79 of 138

176 Copies to: Command Staff, Section Chiefs and Documentation Unit Leader Page 80 of NOTES (including accomplishments, issues, warnings/directives) 7. PREPARED BY (NAME AND POSITION) 8. FACILITY NAME Purpose: Document Initial response information and actions taken at startup Origination: Incident Commander HICS 201 Copies to: Command Staff, Section Chiefs and Documentation Unit Leader Page 2 of 213 Section VII: Page 80 of 138

177 HICS 202 INCIDENT OBJECTIVES 1. INCIDENT NAME 2. DATE PREPARED 3. TIME PREPARED 4. OPERATIONAL PERIOD DATE/TIME 5. GENERAL COMMAND AND CONTROL OBJECTIVES FOR THE INCIDENT (INCLUDING ALTERNATIVES) 6. WEATHER / ENVIRONMENTAL IMPLICATIONS FOR PERIOD (include as appropriate: forecast, wind speed/direction, daylight) 7. GENERAL SAFETY / STAFF MESSAGES TO BE GIVEN (Examples: Personal Protective Equipment (PPE), Precautions, Case Definitions (refer to HICS 261 Incident Action Plan Safety Analysis) 8. ATTACHMENTS (mark if attached) Organization Assignment List - HICS 203 Medical Plan - HICS 206 Traffic Pla Branch Assignment List - HICS 204 Facility System Status Report HICS 251 Incident M Incident Communications Plan - HICS 205 Incident Action Plan Safety Analysis HICS 261 Other 9. PREPARED BY (PLANNING SECTION CHIEF): 10. APPROVED BY (INCIDENT COMMANDER): 11. FACILITY NAME Purpose: Define objectives and issues for operational period. Origination: Planning Section Chief HICS 202 Copies to: Command Staff, General Staff and Documentation Unit Leader Section VII: Page 81 of 138

178 HICS 203 ORGANIZATION ASSIGNMENT LIST 1. INCIDENT NAME 2. DATE PREPARED POSITION 5. Incident Commander and Staff Incident Commander Public Information Officer Liaison Officer Safety Officer Medical/Technical Specialist (Type) Medical/Technical Specialist (Type) 6. Operations Section Chief Staging Manager Medical Care Branch Infrastructure Branch Security Branch Business Continuity Branch HazMat Branch Other Branch: 7. Planning Section Chief Resources Unit Situation Unit Documentation Unit Demobilization Unit Other Branch: 8. Logistics Section Chief Service Branch Support Branch Other Branch: 9. Finance/Administration Section Chief Time Unit Procurement Unit Compensation/Claims Unit Cost Unit NAME / AGENCY Other Branch: 10. Agency Representative (in Hospital Command Center) Agency 3. TIME PREPARED 4. OPERATIONAL PERIOD DATE/TIME 11. Hospital Representative (in External EOC) External Location 12. PREPARED BY (RESOURCES UNIT LEADER) Section VII: Page 82 of 138

179 13. FACILITY NAME HICS BRANCH ASSIGNMENT LIST 1. INCIDENT NAME 5.PERSONNEL SECTION CHIEF 2. SECTION 3. BRANCH BRANCH DIRECTOR 4. OPERATIONAL PERIOD DATE: TIME: 6. UNITS ASSIGNED THIS PERIOD Name Name Name Name Name Name Leader Leader Leader Leader Leader Leader Location Location Location Location Location Location Members Members Members Members Members Members 7. KEY OBJECTIVES 8. SPECIAL INFORMATION / CONSIDERATION 9. PREPARED BY (BRANCH DIRECTOR) 10. APPROVED BY (PLANNING SECTION CHIEF) 11. DATE 12. TIME 13. FACILITY NAME Purpose: Document assignments within branch HICS 204 Origination: Branch Director Section VII: Page 83 of 138

180 HICS 205 INCIDENT COMMUNICATIONS PLAN (INTERNAL) Copies to: Command Staff, General Staff and Documentation Unit Leader Section VII: Page 84 of 138

181 1. INCIDENT NAME 2. DATE/TIME PREPARED 4. BASIC CONTACT INFORMATION ASSIGNMENT/ NAME RADIO CHANNEL / FREQUENCY PHONE Primary & Alternate FAX / PDA PAGER 3. OPERATIONAL PERIOD DATE/TIME ALT. COMMUNICA TION DEVICE COMMENTS 5. PREPARED BY (COMMUNICATIONS UNIT LEADER) 7. FACILITY NAME 6. APPROVED BY (LOGISTICS CHIEF) Section VII: Page 85 of 138

182 HICS 206 STAFF MEDICAL PLAN 1. INCIDENT NAME 2. DATE PREPARED 5. TREATMENT OF INJURED/ ILL STAFF Location of Staff Treatment Area 3. TIME PREPARED Contact Information 4. OPERATIONAL PERIOD DATE/TIME Treatment Area Team Leader Contact Information Special Instructions 6. RESOURCES ON HAND STAFF MEDICAL TRANSPORTATION MEDICATION SUPPLIES MD/DO Litters PA/NP Portable Beds RN/LPN Transport Technicians/CN Wheelchairs Ancillary/Other 7. ALTERNATE CARE SITE(S) NAME ADDRESS PHONE SPECIALTY CARE (specify) 8. PREPARED BY (SUPPORT BRANCH DIRECTOR) 9. FACILITY NAME Section VII: Page 86 of 138

183 HICS 207 ACS ORGANIZATION CHART 1. INCIDENT NAME 2. DATE PREPARED 3. TIME PREPARED 4. OPERATIONAL PERIOD DATE/TIME 5. ORGANIZATIONAL CHART 6. FACILITY NAME Purpose: Document HICS positions assigned Origination: Incident Commander HICS 207 Copies to: Command Staff, General Staff, Branch Directors, Unit Leaders and Documentation Unit Leader Section VII: Page 87 of 138

184 HICS 213 INCIDENT MESSAGE FORM 1. FROM (Sender): 2. TO (Receiver): 3. DATE RECEIVED 4. TIME RECEIVED 5. RECEIVED VIA 6. REPLY REQUESTED: Phone Radio Other Yes No If Yes, REPLY TO (if different from Sender): 7. PRIORITY: Urgent - High Non Urgent Medium Informational - Low 8. MESSAGE (KEEP ALL MESSAGES / REQUESTS BRIEF, TO THE POINT, AND VERY SPECIFIC): 9. ACTION TAKEN (if any): Received by: Time Received: Forward to: Comments: Received by: Time Received: Forward to: Comments: 10. FACILITY NAME Purpose: Provide standardized method for recording messages received by phone or radio Origination: All Positions HICS 213 Original to receiver. Copies to: Documentation Unit Leader and Message Taker Section VII: Page 88 of 138

185 HICS 214 OPERATIONAL LOG 1. INCIDENT NAME 2. DATE/TIME PREPARED 3. OPERATIONAL PERIOD DATE/TIME 4. SECTION /BRANCH 5. POSITION 6. ACTIVITY LOG Time Major Events, Decisions Made, and Notifications Given 7. PREPARED BY (sign and print) 8. FACILITY NAME Purpose: Document incident issues encountered, decisions made and notifications conveyed Origination: Command staff, general staff. Copies to Incident Commander, Planning Section Chief, and Documentation Unit Leader. HICS 214 Section VII: Page 89 of 138

186

187 HICS 251 FACILITY SYSTEM STATUS REPORT 1. Operational Period Date/Time 2. Date Prepared 3. Time Prepared 4. Building Name: 5. SYSTEM STATUS CHECKLIST COMMUNICATION SYSTEM Fax Information Technology System ( /registration/patient records/time card system/intranet, etc.) Nurse Call System Paging - Public Address Radio Equipment Satellite System Telephone System, External Telephone System, Proprietary Video-Television-Internet-Cable Other INFRASTRUCTURE SYSTEM Campus Roadways Fire Detection/Suppression System Food Preparation Equipment Ice Machines OPERATIONAL STATUS Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional OPERATIONAL STATUS Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional COMMENTS (If not fully operational/functional, give location, reason, and estimated time/resources for necessary repair. Identify who reported or inspected.) COMMENTS (If not fully operational/functional, give location, reason, and estimated time/resources for necessary repair. Identify who reported or inspected.) Section VII: Page 90 of 138

188 Laundry/Linen Service Equipment Structural Components (building integrity) PATIENT CARE SYSTEM Decontamination System (including containment) Digital Radiography System (e.g., PACS) Ethylene Oxide (EtO)/Sterilizers Isolation Rooms (positive/negative air) Other SECURITY SYSTEM Door Lockdown Systems Surveillance Cameras Other UTILITIES, EXTERNAL SYSTEM Electrical Power-Primary Service Sanitation Systems Water Natural Gas Other Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional OPERATIONAL STATUS Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional OPERATIONAL STATUS Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional OPERATIONAL STATUS Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional COMMENTS (If not fully operational/functional, give location, reason, and estimated time/resources for necessary repair. Identify who reported or inspected.) COMMENTS (If not fully operational/functional, give location, reason, and estimated time/resources for necessary repair. Identify who reported or inspected.) COMMENTS (If not fully operational/functional, give location, reason, and estimated time/resources for necessary repair. Identify who reported or inspected.) (Reserve supply status) Section VII: Page 91 of 138

189 UTILITIES, INTERNAL SYSTEM Air Compressor Electrical Power, Backup Generator Elevators/Escalators Hazardous Waste Containment System Heating, Ventilation, and Air Conditioning (HVAC) Medical Gases, Other Oxygen Pneumatic Tube Steam Boiler Sump Pump Well Water System Vacuum (for patient use) Water Heater and Circulators Other 6. CERTIFYING OFFICER OPERATIONAL STATUS Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional Fully functional Partially functional Nonfunctional COMMENTS (If not fully operational/functional, give location, reason, and estimated time/resources for necessary repair. Identify who reported or inspected.) (Fuel status) (Reserve supply status) 7. FACILITY NAME Section VII: Page 92 of 138

190

191 HICS Section Personnel Time Sheet 1. FROM DATE/TIME 2. TO DATE/TIME 3. SECTION 4. TEAM LEADER 5. TIME RECORD # Employee (E)/Volunteer (V)* Name (Please Print) E/V Employee Number Response Function/Job Date/Time In Date/Time Out Signature Total Hours * May be usual hospital volunteers or approved volunteers from community. 6. Certifying Officer 7. Date/Time Submitted 8. Facility Name Section VII: Page 93 of 138

192 HICS Volunteer Staff Registration 1. FROM DATE/TIME 2. TO DATE/TIME 3. SECTION 4. TEAM LEADER 5. REGISTRATION Name (Last Name, First Name) Address City, Sate, Zip Social Security Number Telephone Number Certification/ Licensure and Number Time IN Time OUT Signature 6. CERTIFYING OFFICER 7. Date/Time Submitted: 8. Facility Name Section VII: Page 94 of 138

193 HICS DISASTER VICTIM/PATIENT TRACKING FORM 1. INCIDENT NAME 2. DATE/TIME PREPARED 3. OPERATIONAL PERIOD DATE/TIME 4. TRIAGE AREAS (Immediate, Delayed, Expectant, Minor, Morgue) MR#/ Triage # Name Sex DOB/ Age Area Triaged to Location/ Time of Diagnostic Procedures (x-ray, angio, CT, etc.) Time sent to Surgery Disposition (home, admit, morgue, transfer) Time of Disposition 5. SUBMITTED BY 6. AREA ASSIGNED TO 7. DATE/TIME SUBMITTED 8. FACILITY NAME Purpose: Account for victims of identified event seeking medical attention Origination: Situation Unit Leader Copies to: Medical Care Branch Director HICS 254 Section VII: Page 95 of 138

194 HICS 256 PROCUREMENT SUMMARY REPORT 1. PURCHASES P.O./ Reference # Date/Time Item/Service Vendor $ Amount Requestor Name/Dept (Please Print) # 1 Comments 2 Comments 3 Comments 4 Comments 5 Comments 6 Comments 7 Comments 8 Comments 9 Comments 1 0 Comments 1 1 Comments 1 2 Comments 1 3 Comments 2. CERTIFYING OFFICER 3. DATE/TIME SUBMITTED 4. FACILITY NAME Purpose: Summarize and track procurements by operational period and/or incident timeframe Origination: Procurement Unit Leader HICS 256 Copies to: Finance/Administration Section Chief and Documentation Unit Leader Approved By (Please Print) Rec d Date/ Time Section VII: Page 96 of 138

195 HICS 257 RESOURCE ACCOUNTING RECORD 1. DATE 2. SECTION 3. OPERATIONAL PERIOD DATE/TIME 4. RESOURCE RECORD Time Item/ Facility Tracking ID # Condition Received from Dispensed to Returned (Date/Time) Condition (or indicate if nonrecoverable) Initials 5. CERTIFYING OFFICER 6. DATE/TIME SUBMITTED 7. FACILITY NAME Purpose: Track Requested Equipment Origination: Section Chief Copies to: Finance/Administration Section Chief, Resources Unit Leader, and Originator Section VII - Page 97 of 138

196 HICS 258A STAFFING RESOURCE DIRECTORY Physicians: Personal Contact (Company/Agency/Name) Phone Numbers Fax Nursing Laboratory Response Network Laundry/Linen Service Long Term Care Facilities Pharmacy, Commercial Public Health Salvation Army Water - Nonpotable Water Vendor - Potable Other Purpose: List resources to contact as needed and maintain contact information Origination: Resources Unit LeaderPage 98 of 213 Copies to: Command Staff and General Staff HICS 258 Section VII - Page 98 of 138

197 HICS 258 HOSPITAL RESOURCE DIRECTORY Agency for Toxic Substances and Disease Registry (ATSDR) Ambulance/EMS Personal Contact (Company/Agency/Name) Phone Numbers Fax / Radio Ambulance, Hospital- Based Ambulance, Private Ambulance, Public Safety American Red Cross Automated Teller Machine (ATM) Biohazard Waste Company Buses Cab, City CDC Clinics Coroner/Medical Examiner Dispatcher, 911 Emergency Management Agency Emergency Operations Center (EOC), Local Emergency Operations Center (EOC), State Engineers HVAC Mechanical Structural Environmental Protection Agency (EPA) Epidemiologist Federal Bureau of Investigation (FBI) Fire Department Food Service Fuel Section VII - Page 99 of 138

198 Funeral Homes/Mortuary Services Generators Personal Contact (Company/Agency/Name) Phone Numbers Fax / Radio HazMat Team Health Department, Local Heavy Equipment (e.g., Backhoes, etc.) Helicopters Home Repair/Construction Supplies Hospitals Hotel Housing, Temporary Ice, Commercial Laboratory Response Network Laundry/Linen Service Law Enforcement Long Term Care Facilities Media Print: Print: Radio: Radio: TV: TV: TV: TV: Section VII - Page 100 of 138

199 Medical Gases Personal Contact (Company/Agency/Name) Phone Numbers Fax / Radio Medical Supply Medication, Distributor Moving Company Pharmacy, Commercial Poison Control Center Portable Toilets Public Health Radios Amateur Radio Group Satellite Service Provider (e.g., Nextel) Walkie-Talkie Regional Healthcare Coordinating Center/REDDINET Repair Services Beds Biomedical Devices Elevators Medical Devices Oxygen Devices Radios Restoration Services (e.g., ServiceMaster) Salvation Army Section VII - Page 101 of 138

200 Shelter Sites Personal Contact (Company/Agency/Name) Phone Numbers Fax / Radio Surge Facilities Toxicologist Traffic Control Trucks Refrigeration Towing Utilities Gas Power Sewage Telephone Water Vending Machines Ventilators Water - Nonpotable Water Vendor - Potable Other Purpose: List resources to contact as needed and maintain contact information Copies to: Command Staff and General Staff HICS 258 Origination: Resources Unit LeaderPag Section VII - Page 102 of 138

201 Background ACS TARGET FACILITY ASSESSMENTS The Placer County Healthcare Surge Advisory Committee developed a list of criteria for target Alternate Care Sites, prior to conducting site surveys. The criteria included elements such as: proximity to existing acute care facilities (preferably within 1 mile), floor space, existing communications, adequate parking, HVAC, water, bathrooms, and kitchen facilities. Shawn Joyce of S-SV EMS Agency and Douglas Buchanan Consulting conducted the preliminary surveys and provided a summary matrix to the Advisory Committee. Each of the existing acute care hospitals formed Healthcare Survey Teams which then conducted formal site surveys of the facilities within close proximity to the hospital. Additionally, the Advisory Committee recommended identifying facilities in the city of Lincoln due to its population and location in the county. The Advisory Committee plans to conduct site surveys in Lincoln before the summer of APPENDIX D In addition to the criteria listed above, the Advisory Committee considered Public versus Private facilities due to FEMA s facility reimbursement issues presented by OES. Therefore, both public and private facilities were identified in relationship to each existing acute care hospital. The following list depicts the final facilities identified by the Advisory committee, including city, proximity to existing hospitals, and Public or Private status. Facility Nearest Hospital Public/Private Maidu Community Center Kaiser/Sutter Roseville Public Orchid Suites Hotel Kaiser Roseville Private Hilton Gardens Hotel Sutter Roseville Private St. Anna Greek Orth.Church Sutter Roseville Private Regional Park Sutter Auburn Faith Public Holiday Inn Hotel Sutter Auburn Faith Private Section VII - Page 103 of 138

202 Site Name: Maidu Community Center Address: 1550 Maidu Drive, Roseville Thomas Brothers Map and Page grid #: Items to Be Completed Prior to Survey Visit Individual completing assessment: Kaiser Roseville Survey Team (Tom Jones, EP Coordinator) Date of assessment: 11/20/07 Phone: Point of Contact for site access: Joanie Camelon Phone: After business hours point of contact: City of Roseville Phone: Point of Contact for facility maintenance (if applicable): Phone: Point of Contact for site security (if applicable): Phone: Total square feet: Covered square feet: 10,000 40K required if requesting ACS with 250 bed capacity # of buildings available: (circle) One floor or Multilevel # of floors: SINGLE FLOOR The following is a list of basic facility requirements to establish an ACS. Please determine if the requirement is present, not present or reasonably accommodated (potential to be present with refitting/renovation). P = Present; NP = Not Present; RA = Reasonably Accommodated I. Infrastructure P/NP/RA Comments Door size adequate for gurneys P Floors P Loading Dock P Parking for staff and visitors P Massive parking Roof P Toilet facilities/showers (#:_0_) RA One handi-cap shower. Drains in one room. Hand-washing facilities RA No sinks in large rooms. HVAC System for adequate ventilation P Climate Control P Walls P Wheelchair access P II. Total Space P/NP/RA Comments Auxiliary Spaces (Rx, Counselors) P Adequate separate rooms w/locks Equipment/supply storage area P Lock-able rooms, closets Family area P Food and supply prep area P Full kitchen Mortuary holding area RA Patient decontamination/isolation area RA Min 40 sq. feet per bed per person P Staff support/rest break areas P III. Utilities P/NP/RA Comments Air Conditioning P Electrical Power (back up generator) RA No back-up power on site Heating P Lighting P Water P Fire protection safety and equipment P Refrigeration for safe storage of medical supplies P No freezer and food IV. Communications P/NP/RA Comments Phone Capability (#: ) P Two-way radio capability RA Wired for IT and Internet Access P Section VII - Page 104 of 138

203 V. Clinical Requirements P/NP/RA Comments Triage/ER Patient Care RA Pharmacy RA Laboratory/Blood Testing NP Decontamination NP VI. Other Services P/NP/RA Comments Ability to lock down facility RA Provide secure storage for controlled substance RA and medical materials Accessibility/proximity to public transportation P Biohazard & other waste disposal RA Oxygen/medical gases delivery capability RA Please answer the following questions: Has this site been identified for use in other emergencies? Yes, in the City of Roseville s EOP ADA access for persons with disabilities? Yes Size of largest open room: Rec. Hall 4335 square feet** Total covered area sq ft (estimate for 200 casualties +staff = 15,000-20,000): 10,0000 sf + Are there any other indigenous communications resources (i.e. security radios, intercom, Internet etc)? Comments: Wireless internet Generator Capacity: none watts. Fuel on site : none gallons Runtime with existing fuel? 0 Hours 0 Nearest major thoroughfare: Road size and number of lanes for access to site: How does the general layout look? Good Fair Congested Would materiel need to be relocated to use this facility/site? Y N Estimate # of non-ambulatory casualties in all areas (@50 sq. ft. per patient) Problems, major stumbling blocks? Comments. LACK OF HAND-WASHING STATIONS AND SHOWERS MAKE IT DIFFICULT TO OFFER INPATIENT SERVICES FOR CRITICALLY ILL PATIENTS. What would have to be brought in? HAND-WASHING STATIONS, SHOWERS, GENERATOR (EMERGENCY BACK-UP) ACS SUPPLIES (COTS, BEDDING, MEDICAL EQUIPMENT/SUPPLIES) Overall Comments/Recommendation: -CLOSE PROXIMITY TO KAISER ROSEVILLE (1.15 MILES) -EXPANSIVE SPACE, SEPARATE ROOMS, PARKING, KITCHEN ALL MAKE THIS IDEAL FOR OUTPATIENT OR INPATIENT ACS -LARGE GRASS AREAS OFFERS POSSIBILITY FOR MOBILE FIELD HOSPITAL * Site Survey Team: ** Rooms: -Tom Jones -Rec. Hall (85 x 51 ) 4335 sf -Angela Savage, RN, BS -Mtg Room #1 (30 x 38 ) 1140 sf -Betty Goetsch, RN BSN CIC -Mtg Room #2 (23 x 31 ) 713 sf -Doug?, Chief Engineer -Arts & Crafts Rm (34 x 17 ) 578 sf -Tiny Tots Rm (30 x 28 ) 840 sf -Dance Studio (43 x 24 ) 1032 sf -Sen. Act Rm (35 x 20 ) 700 sf -Sen Mtg Rm (37 x 22 ) 814 sf -Plus: Senior Lounge, Lobby, Kitchen, Patios Section VII - Page 105 of 138

204 Site Name: Orchid Suites Hotel Address: 130 North Sunrise, Roseville Thomas Brothers Map and Page grid #: Items to Be Completed Prior to Survey Visit Individual completing assessment: Kaiser Roseville Survey Team (Tom Jones, EP Coordinator) Date of assessment: 11/20/07 Phone: Point of Contact for site access: Merlyn Landaker, Director of Sales Phone: After business hours point of contact: Munzer Baseiso, General Manager Phone: Point of Contact for facility maintenance (if applicable): Phone: Point of Contact for site security (if applicable): Phone: Total square feet: Covered square feet: 1000 sf Conference Room Guest Rooms 40K required if requesting ACS with 250 bed capacity # of buildings available: (circle) One floor or Multilevel # of floors: Multi-LEVEL The following is a list of basic facility requirements to establish an ACS. Please determine if the requirement is present, not present or reasonably accommodated (potential to be present with refitting/renovation). P = Present; NP = Not Present; RA = Reasonably Accommodated I. Infrastructure P/NP/RA Comments Door size adequate for gurneys P Floors P Loading Dock P Parking for staff and visitors P Roof P Toilet facilities/showers (#: ) P Showers at Pool + guest rooms Hand-washing facilities RA No sink in conference room. HVAC System for adequate ventilation P Climate Control P Walls P Wheelchair access P II. Total Space P/NP/RA Comments Auxiliary Spaces (Rx, Counselors) P Adequate separate rooms w/locks Equipment/supply storage area P Closets in conference room + lounge Family area P Dining area, plus outdoor patio Food and supply prep area P Full kitchen Mortuary holding area RA Patient decontamination/isolation area RA Min 40 sq. feet per bed per person P Staff support/rest break areas P Dining area, outdoor patio, guest rooms III. Utilities P/NP/RA Comments Air Conditioning P Electrical Power (back up generator) RA No back-up power on site Heating P Lighting P Water P Fire protection safety and equipment P Refrigeration for safe storage of medical supplies P and food IV. Communications P/NP/RA Comments Phone Capability (#: ) P Two-way radio capability RA Wired for IT and Internet Access P Wireless internet V. Clinical Requirements P/NP/RA Comments Section VII - Page 106 of 138

205 Triage/ER Patient Care RA Pharmacy RA Laboratory/Blood Testing NP Decontamination NP VI. Other Services P/NP/RA Comments Ability to lock down facility RA Provide secure storage for controlled substance RA and medical materials Accessibility/proximity to public transportation P Biohazard & other waste disposal RA Oxygen/medical gases delivery capability RA Please answer the following questions: Has this site been identified for use in other emergencies? No ADA access for persons with disabilities? Yes Size of largest open room: Conference Room 1000 square feet Total covered area sq ft (estimate for 200 casualties +staff = 15,000-20,000): Are there any other indigenous communications resources (i.e. security radios, intercom, Internet etc)? Comments: Wireless internet Generator Capacity: none watts. Fuel on site : none gallons Runtime with existing fuel? 0 Hours 0 Nearest major thoroughfare: Road size and number of lanes for access to site: How does the general layout look? Good Fair Congested Would materiel need to be relocated to use this facility/site? Y N Estimate # of non-ambulatory casualties in all areas (@50 sq. ft. per patient) Problems, major stumbling blocks? Comments. What would have to be brought in? GENERATOR (EMERGENCY BACK-UP) ACS SUPPLIES (COTS, MEDICAL EQUIPMENT/SUPPLIES) Overall Comments/Recommendation: -CLOSE PROXIMITY TO KAISER ROSEVILLE (1.24 MILES) -SEPARATE ROOMS AND KITCHEN ALL MAKE THIS IDEAL FOR OUTPATIENT OR INPATIENT ACS -ON-SITE LAUNDRY A PLUS -INDOOR ACCESS BUILDING (HOTEL) COULD BE CLOSED OFF FOR ACS * Site Survey Team: -Tom Jones -Angela Savage, RN, BS -Betty Goetsch, RN BSN CIC -Doug?, Chief Engineer Section VII - Page 107 of 138

206 Site Name: Hilton Garden Hotel Address: 1951 Taylor Road, Roseville Thomas Brothers Map and Page grid #: Items to Be Completed Prior to Survey Visit Individual completing assessment: Sutter Roseville Survey Team (Barbara Todd, EP Coordinator) Date of assessment: 11/20/07 Phone: Point of Contact for site access: Jessica Sacci, General Manager Phone: After business hours point of contact: Phone: Point of Contact for facility maintenance (if applicable): Phone: Point of Contact for site security (if applicable): Phone: Total square feet: Covered square feet: 1000 sf Conference Room Guest Rooms 40K required if requesting ACS with 250 bed capacity # of buildings available: (circle) One floor or Multilevel # of floors: Multi-LEVEL The following is a list of basic facility requirements to establish an ACS. Please determine if the requirement is present, not present or reasonably accommodated (potential to be present with refitting/renovation). P = Present; NP = Not Present; RA = Reasonably Accommodated I. Infrastructure P/NP/RA Comments Door size adequate for gurneys P Floors P Loading Dock P Parking for staff and visitors P Roof P Toilet facilities/showers (#:131) P Guest rooms + Lobby Hand-washing facilities RA No sink in conference room. HVAC System for adequate ventilation P Climate Control P Walls P Wheelchair access P II. Total Space P/NP/RA Comments Auxiliary Spaces (Rx, Counselors) P Adequate separate rooms w/locks Equipment/supply storage area P Closets in conference room Family area P Dining area, plus outdoor patio Food and supply prep area P Full kitchen Mortuary holding area RA Patient decontamination/isolation area RA Min 40 sq. feet per bed per person P Staff support/rest break areas P Dining area, outdoor patio, guest rooms III. Utilities P/NP/RA Comments Air Conditioning P Electrical Power (back up generator) RA No back-up power on site Heating P Lighting P Water P Fire protection safety and equipment P Refrigeration for safe storage of medical supplies P and food IV. Communications P/NP/RA Comments Phone Capability (#: ) P Two-way radio capability RA Wired for IT and Internet Access P Wireless internet Section VII - Page 108 of 138

207 V. Clinical Requirements P/NP/RA Comments Triage/ER Patient Care RA Pharmacy RA Laboratory/Blood Testing NP Decontamination NP VI. Other Services P/NP/RA Comments Ability to lock down facility RA Provide secure storage for controlled substance RA and medical materials Accessibility/proximity to public transportation P Biohazard & other waste disposal RA Oxygen/medical gases delivery capability RA Please answer the following questions: Has this site been identified for use in other emergencies? No ADA access for persons with disabilities? Yes Size of largest open room: Conference Room 1000 square feet Total covered area sq ft (estimate for 200 casualties +staff = 15,000-20,000): Are there any other indigenous communications resources (i.e. security radios, intercom, Internet etc)? Comments: Wireless internet Generator Capacity: none watts. Fuel on site : none gallons Runtime with existing fuel? 0 Hours 0 Nearest major thoroughfare: Road size and number of lanes for access to site: How does the general layout look? Good Fair Congested Would materiel need to be relocated to use this facility/site? Yes Estimate # of non-ambulatory casualties in all areas (@50 sq. ft. per patient) Problems, major stumbling blocks? Comments. What would have to be brought in? GENERATOR (EMERGENCY BACK-UP) ACS SUPPLIES (COTS, MEDICAL EQUIPMENT/SUPPLIES) Overall Comments/Recommendation: -CLOSE PROXIMITY TO SUTTER ROSEVILLE (.63 MILES) -SEPARATE ROOMS AND KITCHEN ALL MAKE THIS IDEAL FOR OUTPATIENT OR INPATIENT ACS -ON-SITE LAUNDRY A PLUS -WING OF HOTEL COULD BE CLOSED OFF FOR ACS. * Site Survey Team: -Barbara Todd, RN Section VII - Page 109 of 138

208 Site Name: St. Anna s Greek Orthodox Church Address: 1001 Stone Canyon Drive, Roseville Thomas Brothers Map and Page grid #: Items to Be Completed Prior to Survey Visit Individual completing assessment: Sutter Roseville Survey Team (Barbara Todd, EP Coordinator) Date of assessment: 11/20/07 Phone: Point of Contact for site access: Father Christopher Flesoras Phone: After business hours point of contact: Phone: Point of Contact for facility maintenance (if applicable): Phone: Point of Contact for site security (if applicable): Phone: Total square feet: Covered square feet: 2500 sf + classrooms 40K required if requesting ACS with 250 bed capacity # of buildings available: (circle) One floor or Multilevel # of floors: MULTI- FLOOR The following is a list of basic facility requirements to establish an ACS. Please determine if the requirement is present, not present or reasonably accommodated (potential to be present with refitting/renovation). P = Present; NP = Not Present; RA = Reasonably Accommodated I. Infrastructure P/NP/RA Comments Door size adequate for gurneys P Floors P Loading Dock P Parking for staff and visitors P Roof P Toilet facilities/showers (#:_0_) P No showers Hand-washing facilities RA No sink in church hall (large room) HVAC System for adequate ventilation P Climate Control P Walls P Wheelchair access P II. Total Space P/NP/RA Comments Auxiliary Spaces (Rx, Counselors) P Adequate separate rooms w/locks Equipment/supply storage area P Lock-able rooms, closets Family area P Indoor + outdoor child areas Food and supply prep area P Full kitchen Mortuary holding area RA Patient decontamination/isolation area RA Min 40 sq. feet per bed per person P Staff support/rest break areas P III. Utilities P/NP/RA Comments Air Conditioning P Electrical Power (back up generator) RA No back-up power on site Heating P Lighting P Water P Fire protection safety and equipment P Refrigeration for safe storage of medical supplies P and food IV. Communications P/NP/RA Comments Phone Capability (#: ) P Two-way radio capability RA Wired for IT and Internet Access P Wireless internet on-site Section VII - Page 110 of 138

209 V. Clinical Requirements P/NP/RA Comments Triage/ER Patient Care RA Pharmacy RA Laboratory/Blood Testing NP Decontamination NP VI. Other Services P/NP/RA Comments Ability to lock down facility RA Provide secure storage for controlled substance RA and medical materials Accessibility/proximity to public transportation P Biohazard & other waste disposal RA Oxygen/medical gases delivery capability RA Please answer the following questions: Has this site been identified for use in other emergencies? No ADA access for persons with disabilities? Yes Size of largest open room: 2500 square feet Total covered area sq ft (estimate for 200 casualties +staff = 15,000-20,000): 5000 sf + Are there any other indigenous communications resources (i.e. security radios, intercom, Internet etc)? Comments: Wireless internet Generator Capacity: none watts. Fuel on site : none gallons Runtime with existing fuel? 0 Hours 0 Nearest major thoroughfare: Road size and number of lanes for access to site: How does the general layout look? Good Fair Congested Would materiel need to be relocated to use this facility/site? Yes Estimate # of non-ambulatory casualties in all areas (@50 sq. ft. per patient) 50 Problems, major stumbling blocks? Comments. LACK OF HAND-WASHING STATIONS AND SHOWERS MAKE IT DIFFICULT TO OFFER INPATIENT SERVICES FOR CRITICALLY ILL PATIENTS. What would have to be brought in? HAND-WASHING STATIONS, SHOWERS, GENERATOR (EMERGENCY BACK-UP) ACS SUPPLIES (COTS, BEDDING, MEDICAL EQUIPMENT/SUPPLIES) Overall Comments/Recommendation: -CLOSE PROXIMITY TO SUTTER ROSEVILLE (.72 MILES) -LOCATION, SEPARATE ROOMS, PARKING, KITCHEN ALL MAKE THIS IDEAL FOR OUTPATIENT OR INPATIENT ACS * Site Survey Team: -Barbara Todd, RN Section VII - Page 111 of 138

210 Site Name: Regional Park GYM Address: 3770 Richardson Dr, Auburn Thomas Brothers Map and Page grid #: Items to Be Completed Prior to Survey Visit Individual completing assessment: Sutter Auburn Faith Survey Team (Jill Meeh, EP Coordinator) Date of assessment: 12/11/07 Phone: Point of Contact for site access: DARRIN VAN DYKE Phone: After business hours point of contact: Point of Contact for facility maintenance (if applicable): Point of Contact for site security (if applicable): Total square feet: Lakeside Room- This 1365 sq ft. Gym: 5000 sf Phone: Phone: Phone: Covered square feet: 2000 sf plus 40K required if requesting ACS with 250 bed capacity # of buildings available: 3-4 (circle) One floor or Multilevel # of floors: The following is a list of basic facility requirements to establish an ACS. Please determine if the requirement is present, not present or reasonably accommodated (potential to be present with refitting/renovation). P = Present; NP = Not Present; RA = Reasonably Accommodated I. Infrastructure P/NP/RA Comments Door size adequate for gurneys P Floors P In gym Loading Dock NP Parking for staff and visitors P Roof P Toilet facilities/showers (#: ) P 2 shower stalls Hand-washing facilities P limited HVAC System for adequate ventilation P Climate Control P Walls P Wheelchair access P II. Total Space P/NP/RA Comments Auxiliary Spaces (Rx, Counselors) NP Equipment/supply storage area NP Family area NP Food and supply prep area P Very limited Mortuary holding area NP Patient decontamination/isolation area NP Min 40 sq. feet per bed per person P Staff support/rest break areas P limited III. Utilities P/NP/RA Comments Air Conditioning P Electrical Power (back up generator) NP Could add generator to power supply box Heating P Lighting P poor Water P Only in toilets & kitchen Fire protection safety and equipment P limited Refrigeration for safe storage of medical supplies P Food not meds and food IV. Communications P/NP/RA Comments Section VII - Page 112 of 138

211 Phone Capability (#: ) P Limited to three lines Two-way radio capability P Wired for IT and Internet Access NP V. Clinical Requirements P/NP/RA Comments Triage/ER Patient Care P Pharmacy NP Laboratory/Blood Testing NP Decontamination NP VI. Other Services P/NP/RA Comments Ability to lock down facility P Provide secure storage for controlled substance NP and medical materials Accessibility/proximity to public transportation? Biohazard & other waste disposal NP Oxygen/medical gases delivery capability NP Please answer the following questions: Has this site been identified for use in other emergencies? unknown ADA access for persons with disabilities? P Size of largest open room: Total covered area sq ft (estimate for 200 casualties +staff = 15,000-20,000): Are there any other indigenous communications resources (i.e. security radios, intercom, Internet etc)? Comments: Generator Capacity: none watts. Fuel on site: X none gallons Runtime with existing fuel? Hours Nearest major thoroughfare: hwy 49 Road size and number of lanes for access to site: How does the general layout look? Good XFair Congested Would materiel need to be relocated to use this facility/site? X Y N Estimate # of non-ambulatory casualties in all areas (@50 sq. ft. per patient) Problems, major stumbling blocks? Comments. This site has no E-power and limited toilet hand washing facilities, also lacks kitchen and storage areas. What would have to be brought in? Everything for patient care --- Overall Comments/Recommendation: I would recommend this site be primarily used for Triage or dispensing site.this site not suitable for inpatient care. * Site Survey Team: Section VII - Page 113 of 138

212 Site Name: Holiday Inn Address: 120 Grass Valley Highway, Auburn Thomas Brothers Map and Page grid #: Items to Be Completed Prior to Survey Visit Individual completing assessment: Sutter Auburn Faith Survey Team (Jill Meeh, EP Coordinator) Date of assessment: 12/11/07 Phone: Point of Contact for site access: Mary Macleod, General Manager Phone: (530) After business hours point of contact: Point of Contact for facility maintenance (if applicable): Point of Contact for site security (if applicable): Phone: Phone: Phone: Total square feet: Covered square feet: 3 Conference rooms, (1400 sf +) + 96 guest rooms 40K required if requesting ACS with 250 bed capacity # of buildings available: (circle) One floor or Multilevel # of floors: Mutli-level The following is a list of basic facility requirements to establish an ACS. Please determine if the requirement is present, not present or reasonably accommodated (potential to be present with refitting/renovation). P = Present; NP = Not Present; RA = Reasonably Accommodated I. Infrastructure P/NP/RA Comments Door size adequate for gurneys P Floors P Carpet & Tile Loading Dock P Parking for staff and visitors P Roof P Toilet facilities/showers (#: ) P Toilet,sink and shower in each room Hand-washing facilities P HVAC System for adequate ventilation P Climate Control P Each room climate controlled individual ally Walls P Wheelchair access P II. Total Space P/NP/RA Comments Auxiliary Spaces (Rx, Counselors) P 3 large conference rooms could be used for pt care or equipment, pharmacy etc. Equipment/supply storage area P Family area P Food and supply prep area P In house restaurant Mortuary holding area P Could be placed in climate controlled small confrere room Patient decontamination/isolation area NP Min 40 sq. feet per bed per person Unsure Staff support/rest break areas P III. Utilities P/NP/RA Comments Air Conditioning P Each room Electrical Power (back up generator) NP Heating P Lighting P Water P Section VII - Page 114 of 138

213 Fire protection safety and equipment P Refrigeration for safe storage of medical supplies P and food IV. Communications P/NP/RA Comments Phone Capability (#: ) P Two-way radio capability NP Wired for IT and Internet Access P In large conference room only V. Clinical Requirements P/NP/RA Comments Triage/ER Patient Care NP Pharmacy NP Laboratory/Blood Testing NP Decontamination NP VI. Other Services P/NP/RA Comments Ability to lock down facility P Provide secure storage for controlled substance Unsure and medical materials Accessibility/proximity to public transportation P Adjacent to I -80 Biohazard & other waste disposal NP Oxygen/medical gases delivery capability NP Please answer the following questions: Has this site been identified for use in other emergencies? Unsure ADA access for persons with disabilities? P Size of largest open room: 1400 sf Total covered area sq ft (estimate for 200 casualties +staff = 15,000-20,000): 3 Conference rooms, (1400 sf +) + 96 guest rooms Are there any other indigenous communications resources (i.e. security radios, intercom, Internet etc)? Comments: Phones in each room Generator Capacity: X none watts. Fuel on site :? none gallons Runtime with existing fuel? Hours Nearest major thoroughfare: I-80 Road size and number of lanes for access to site: Hwy 49 How does the general layout look? XGood Fair Congested Would materiel need to be relocated to use this facility/site? X Y N Estimate # of non-ambulatory casualties in all areas (@50 sq. ft. per patient) Problems, major stumbling blocks? Comments. None What would have to be brought in? All patient care supplies, Generator if needed, Overall Comments/Recommendation: This site looked good I liked the larger hotel rooms as well as conference rooms for patient care this could also be Triage /Dispensing site.this site could also be used to house healthcare workers exposed to blank unable to go home.i feel this site has the most potential although as with the other site all patient care items would need to be brought to this facility. * Site Survey Team: Section VII - Page 115 of 138

214 Section VII - Page 116 of 138

215 ACS FACILITY MOU APPENDIX E Section VII - Page 117 of 138

216 **DRAFT** PLACER COUNTY MEMORANDUM OF UNDERSTANDING (MOU) FOR USE OF FACILITIES IN THE EVENT OF A MASS MEDICAL EMERGENCY Placer County, and (name of facility) agree that: In the event of a mass medical emergency in Placer County, health and medical infrastructure and associated resources will be quickly committed to providing the necessary treatment and/or prophylaxis to effectively respond by request of the Medical/Health Operational Area Coordinator. Resources from the state, federal, and private sector will be mobilized and deployed to augment local medical and health resources as soon as possible. Such an event may require a facility to support the activation of an Alternate Care Site (ACS). The ACS will serve as a site where supportive care can be provided to victims of a large-scale mass casualty or bio-event. Placer County and (name of facility) enter into this partnership as follows: 1. Facility Space: Placer County accepts designation of (name of facility) located at (address of facility) as an Alternate Care Site (ACS), in the event the need arises. 2. Use of the Facility: Request to use facility as an ACS will occur as soon as possible by the Placer County Medical/Health Operational Area Coordinator, through the local Emergency Operations Center. Designation and use of (name of facility) will be mutually agreed upon by all parties to this agreement. 3. Modification or Suspension of Normal Facility Business Activities: (name of facility) agrees to alter or suspend normal operations in support of the ACS as needed. 4. Use of Facility Resources: (name of facility) agrees to authorize the use of facility equipment such as forklifts, buildings, communications equipment, computers, Internet services, copying equipment, fax machines, etc. Facility resources and associated systems will only be used with facility management authorization and oversight to include appropriate orientation/training as needed. 5. Costs: a. Public Facilities: All reasonable and eligible costs associated with the emergency and the operation of the ACS that include modifications or damages to the facility structure, equipment and associated systems directly related to their use in support of the ACS facility operations will be submitted for consideration and reimbursement through established disaster assistance programs. b. Private Facilities: (name of facility) agrees to enter into a Disaster Operations Agreement with a local government entity for use of facilities upon declaration of an emergency. All reasonable and eligible costs associated with the support of the ACS will be submitted for consideration and reimbursement through established disaster assistance programs, as mutually agreed upon in the Disaster Operations Agreement. 6. Liability: The California Emergency Services Act, Government Code 204 Disaster Service Workers addresses immunity from liability for services rendered voluntarily and without compensation in support of emergency operations during an emergency or disaster declared by the Governor. Section VII - Page 118 of 138

217 7. Contact Information: (name of facility) will provide Placer County the appropriate facility 24 hour/7 day contact information, and update this information as necessary. 8. Duration of Agreement: The minimum term of this MOU is two years from the date of the initial agreement. Subsequent terms may be longer with the concurrence of all parties. 9. Agreement Review: A review will be initiated by Placer County and conducted following a disaster event or within two years after the effective date of this agreement. At that time, this agreement may be negotiated for renewal. Any changes at the facility that could impact the execution of this agreement will be conveyed to the identified primary contacts or their designees of this agreement as soon as possible. All significant communications between the Parties shall be made through the contacts or their designees. 10. Amendments: This agreement may be amended at any time by signature approval of the signatories or their respective designees. 11. Termination of Agreement: Any Party may withdraw at any time from this MOU, except as above, by transmitting a signed statement to that effect to the other Parties. This MOU and partnership created thereby will be considered terminated thirty (30) days from the date nonwithdrawing Party receives the notice of withdrawal from the withdrawing Party. 12. Capacity to Enter into Agreement: The persons executing this MOU on behalf of their respective entities hereby represent and warrant that they have the right, power, legal capacity, and appropriate authority to enter into this MOU on behalf of the entity for which they sign. Facility Official Date (County) Official Date Public Health Department Official Date Hospital Official Date To authorize facility use, call: Name Daytime phone number After-hours/emergency phone number To open facility, call: Name Daytime phone number After-hours/emergency phone number Alternate contact to open facility, call: Name Daytime phone number After-hours/emergency phone number Section VII - Page 119 of 138

218 Section VII - Page 120 of 138

219 APPENDIX F Placer County Medical Resource Request Form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ate/Time: Complete & fax; Attn: Dr Burton/Vickie Pinette, C/O Placer County OES: (530) Revised: November 12, 2007 Section VII - Page 121 of 138

220 Placer Medical Resource Request Form 1. Date and Time Mission/Request Tasking Form submitted. 2. Operational Area or County Name INSTRUCTIONS 3. Priority Key: Flash (Imminent threat of death), High (Potential threat of death or Imminent property damage), Medium (Potential property damage), Low (Routine) 4. Status Key: Black (Critical Action Required), Red (Action Required), Orange (En route), Yellow (on scene), Green (released), Gray (canceled), Blue (closed) 5. Number assigned by local jurisdiction or Operational Area. 6. Optional number assigned by requesting agency. 7. Contact Information for Agency/Facility requesting resources. 8. Incident resource responsible for supplying logistical support 9. Name of overall disaster or incident if any (e.g. Bay Area Earthquake, Northern CA Floods, San Diego Wildfire, etc.) 10. Name of Incident for which resources are being requested (i.e. name assigned by Incident Commander). 11.a. Sequential Number assigned by facility or jurisdiction for this request e.g. E-001, O-001, etc. (E= Equipment, A= Aircraft, O=Overhead). 11. b. Specific Type and Kind of Resource being requested (e.g. Operating Room RNs, ALS Ambulance, etc.) 11.c. Quantity in which resource is being requested (e.g. each, box, carton, gaggle). 11.d. Estimated cost assigned by requestor for this resource (Same as 11 a. d.) 15. Additional items that the requested resource is expected to provide (e.g. 72 hours of drinking water/food, etc.) 16. Specific task(s) this resource will be expected to perform (e.g. Provide shelter stand-by, transport patients, triage, etc.) 17. Specific date and time resource is needed. 18. a. Name of Location to which the resource is to report (e.g. Holiday Inn, County Fairgrounds, 7-11 Parking Lot, etc.) 18. b. Name of Individual or Position to which the resource is to report, and means of contact (i.e. phone number, radio freq., etc) 18. c-g. Location details for where the resource is to report or be delivered. 19. Any special instructions for delivery of the resource (e.g. Preferred Access route, Safety Instructions, etc.) 20. Name, Position, and Contact Information for the individual to whom the request will be forwarded., e.g. RDMHC/S. (To be completed by the individual receiving the request, e.g. MHOAC) 21. Name and contact information for the Vendor/Agency identified to fill the request. 22. Name and contact information of the individual receiving the request (e.g. MHOAC). Date and Time the request was forwarded. -Fax completed form to: Attn: Dr Burton/Vickie Pinette, C/O Placer County OES: (530) Section VII - Page 122 of 138

221 APPENDIX G Placer County Healthcare Coalition Mutual Aid Memorandum of Understanding for Healthcare Facilities January 2008 Introduction and Background The healthcare facilities located within Placer County are all susceptible to a disaster that could exceed the resources of any one individual facility. Disasters can result from incidents generating an overwhelming number of patients, or smaller groups of patients whose specialized medical requirements exceed the resources of the impacted facility (e.g., hazmat injuries, pulmonary, trauma surgery, etc.), or from incidents such as building or plant problems, terrorist acts, bomb threats, etc., that impact a facility s operational capability. Scope The scope of this plan encompasses all participating healthcare facilities located within Placer County. MAP OF PLACER COUNTY HEALTHCARE FACILITIES Section VII - Page 123 of 138

222 Purpose of Mutual Aid Memorandum of Understanding The mutual aid concept is well established and is considered standard of care in most emergency response disciplines, including fire services, emergency medical services (EMS) and law enforcement. The purpose of this mutual aid agreement is to assist healthcare facilities achieve an effective level of disaster medical preparedness by authorizing the exchange of personnel, pharmaceuticals, supplies, equipment, and/or information. In addition, healthcare facilities participating in this agreement are committed to assisting each other with transfer and receipt of patients in the event a facility is rendered incapable of patient care and must relocate its patients. This Mutual Aid Memorandum of Understanding (MOU) is a voluntary agreement between the participating Placer County healthcare facilities. This document only addresses the relationship between and among healthcare providers and is intended to augment, not replace, each facility s disaster plan. Moreover, this document does not replace but rather supplements the rules and procedures governing interaction with other organizations during a disaster, e.g., law enforcement agencies, the Emergency Management agencies, fire departments, American Red Cross, civil defense offices, etc. By signing this Memorandum of Understanding, healthcare facilities are evidencing their intent to abide by the terms of the MOU as described below. The terms of this MOU are to be incorporated into each healthcare facility s disaster plan. Definition of Terms Command Center: An area established within a healthcare facility during an emergency that is the facility s primary source of administrative authority and decision-making. Donor Healthcare The healthcare facility that provides personnel, pharmaceuticals, Facility: supplies, equipment, and/or information to the Emergency Operations Center (EOC) or a facility experiencing a medical disaster. Impacted Healthcare manage a A healthcare facility that has exceeded its capability to Facility: disaster with its own internal resources. This is also referred to as the recipient healthcare facility when pharmaceuticals, supplies, equipment, and/or information are requested or as the patient transferring healthcare facility when the evacuation of patients is required. Section VII - Page 124 of 138

223 Medical Disaster: Emergency allowing for the Operations Center (EOC): An event that a facility cannot appropriately resolve solely by using its own resources and may involve temporarily utilizing medical and support personnel, pharmaceuticals, supplies, or equipment, and/or information from another facility. This type of event may also necessitate the need for transport of patients to other participating healthcare facilities. A communication center with network capabilities immediate determination of available healthcare facility resources at the time of a disaster. The EOC is operational 24-hours a day and requires daily maintenance. The EOC may assume a command/control function during a disaster. Logistics coordinated by the EOC include identifying the number and specific location where personnel, pharmaceuticals, supplies, equipment, patients, and/or information should be sent, how to enter the security perimeter; estimated time interval between arrivals and estimated return dates of borrowed supplies, etc. Patient Accepting The healthcare facility that accepts transferred patients from a facility Healthcare Facility: experiencing a medical disaster. When patients are evacuated, the receiving facility is referred to as the patient accepting healthcare facility. Patient Transferring The healthcare facility that evacuates patients to a patient accepting Healthcare Facility: facility in response to a medical disaster. Recipient The healthcare facility where the disaster occurred and has requested Healthcare Facility: personnel or materials from another facility. Also referred to as the patient-transferring healthcare facility when involving evacuating and/or transferring patients during a medical Disaster. Alternate Care Site (ACS): A location designated by the patient transferring healthcare facility or local/state/federal Emergency Management officials where patients will be sent for treatment and/or Section VII - Page 125 of 138

224 observation should the disaster overwhelm capacity of participating healthcare facilities of this MOU. Emergency A committee designed to develop and implement preparedness plans Preparedness and response protocols for disaster management. Representatives on Committee (EPC): this committee include, but are not limited to, Emergency Medical/Ambulance Services, Fire Response Services, Law Enforcement, Healthcare Facilities, State and county Emergency Management and Health Departments, Medi-flight, etc. Regional Trauma A committee designed to address and respond to concerns related to the Advisory Board: trauma management system within a defined geographic region. MHOAC Medical/Health Operational Area Coordinator (MHOAC). An individual jointly appointed by the Local Health Officer and EMS Director who is responsible in the event of a disaster or major incident where mutual aid is requested, for obtaining and coordinating services and allocation of resources within the Operational Area (county). Healthcare Facility An individual located at the healthcare facility designated by the Healthcare Liaison: Facility s Incident Commander to communicate with the MHOAC. Disaster Control center that has Facility (DCF): A community communication and information communication capabilities allowing for the immediate determination of available healthcare facility resources at the time of a disaster. The Control Facility is operational 24 hours a day. Medical A group of credentialed volunteers which include medical and public Reserve Corps health professionals such as physicians, nurses, pharmacists, (MRC): emergency medical technicians, dentists, veterinarians, epidemiologists, and infectious disease specialists. Section VII - Page 126 of 138

225 EMSystems: An internet-based system used by healthcare facilities to report open/closed/divert status in real-time. Healthcare The Executive Council is a policy group comprised of representatives Coalition from hospitals, clinics, long-term care, mental health, EMS, OES, and Executive Council: public health to evaluate and approve processes related to mutual aid (HCEC): not specified within this document. General Terms of this Agreement 1. Agreement to Share Resources: To the best of their ability, each healthcare facility participating in this MOU agrees to share the following resources during a disaster: Personnel (that have been appropriately credentialed, i.e. MRC) Equipment Supplies Pharmaceuticals Information Financial & Legal: The recipient healthcare facility will assume legal responsibility for the personnel and equipment from the donor healthcare facility during the time the personnel equipment and supplies are at the recipient healthcare facility. The recipient healthcare facility will reimburse the donor healthcare facility, for the donor healthcare facility's actual costs of providing personnel and assistance. Costs includes, but are not limited to, all the use, and return costs of borrowed materials, the replacement of any damaged or lost equipment, cost of borrowed personnel s salary and benefits Reimbursement will be made within ninety days following receipt of the invoice. Documentation of cost incurred will be standardized throughout the participating hospitals. 2. Standardized Communication and Coordination Systems: Each healthcare facility participating in this MOU agrees to implement and/or adopt the following systems: An incident command and control system consistent with the National Incident Management System (i.e. HICS) A universal emergency code system consistent for all healthcare facilities in Placer County. The emergency code system currently in place at most facilities consists of the following: o Code Red Fire Section VII - Page 127 of 138

226 o Code Blue Medical Emergency / Cardiac Respiratory Arrest o Code Yellow Bomb Threat o Code Orange Hazardous Material Spill/Release o Code Pink Infant Abduction o Code Purple Child Abduction o Code Triage Internal/External Disaster o Code Silver Person with a Weapon or hostage situation o Code Grey Combative Person o A facility may choose to implement other codes in addition to the universal codes Standardized triage tags and documentation packs Utilization of a standard communication system such as satellite phones, ham radios, or the HEAR system. Through the Emergency Preparedness Committee, facilities will collaborate on a communication system that ensures a dedicated, secure, and reliable method to communicate with the EOC and other healthcare facilities. Utilization of a web-based communication system. (The current system in use is EMSystems) 3. Implementation of Mutual Aid Memorandum of Understanding: Only the Incident Commander at each healthcare facility has the authority to begin implementing the Mutual Aid MOU. This is achieved by contacting the MHOAC. The county EOC may be activated through the direction and authority of Placer County Office of Emergency Services. 4. Command Center: The facility s command center is responsible for informing the MHOAC of its situation and of any needs or available resources. The Healthcare Facility s Incident Commander or designee is responsible for requesting personnel, pharmaceuticals, supplies, equipment, information or authorizing the evacuation of patients. Via the EOC, the healthcare facility s Incident Commander or designee will coordinate, both internally and with the donor/patient-accepting healthcare facility, all of the logistics involved in implementing this Mutual Aid MOU. 5. Exercise Coordination: Each healthcare facility will participate in drills that include communicating to the MHOAC a set of data elements or indicators describing the healthcare facility s resource capacity. The MHOAC will serve as an information center for recording and disseminating the type and amount of available resources at each healthcare facility. During a disaster drill or disaster, each healthcare facility will report to the MHOAC the Section VII - Page 128 of 138

227 current status of its indicators. In addition to signing this agreement, healthcare facilities agree to participate in two (2) community-wide emergency response drills per year. 6. Public Relations: Each healthcare facility is responsible for developing and coordinating with other facilities and relevant organizations its media response to the disaster. Healthcare facilities are encouraged to develop and coordinate the outline of their response prior to any disaster. 7. Education & Training: Each healthcare facility is responsible for disseminating the information regarding this MOU to relevant facility personnel. 8. Alternate Care Site: Each healthcare facility agrees to assist in the operations of alternate care sites as a regional medical response. 9. Daily Collection of Data: Each healthcare facility agrees to provide key indicators to a web-based communication system that is managed by Region IV. Each facility also agrees, if requested, to participate in daily and quarterly reporting as determined by needs of the community and state. 10. Divert Status: The Control Facility will not place any healthcare facility on divert because of information gathered during a disaster. 11. Patient Information: During disasters each healthcare facility agrees to provide relevant patient information as necessary to assist with the public health function response. Standard Operating Procedures Governing Medical Operations, the Loaning of Personnel, Transfer of Pharmaceuticals, Supplies or Equipment, or the Evacuation of Patients (SEE ALSO REGION IV MUTUAL AID PROCEDURES MANUAL 3) NOTE: This agreement recognizes there are pre-existing informal assistance/sharing networks among healthcare facilities. The process below is designed to augment current processes, not necessarily to replace them. Medical Operations/Loaning Personnel 1. Communication of Request: The request for the transfer of personnel initially can be made verbally to the MHOAC. The request, however, must be followed-up with written or Section VII - Page 129 of 138

228 electronic documentation. The recipient healthcare facility will identify to the MHOAC the following: a. The type, by job function, and number of needed personnel. b. An estimate of how quickly the request should be met. c. The location and contact person to whom they are to report. d. An estimate of how long the personnel will be needed. e. The entry point for donated personnel at the recipient healthcare facility. MHOAC will maintain a database of credentialed personnel, as well as a map of each healthcare facility with designated parking and entry areas. Credentials will be provided to the recipient healthcare facility for their records at the conclusion of the disaster response, or the recipient healthcare facility may contact the MHOAC at anytime to verbally verify the credentials of a MRC responder. 2. Documentation: The arriving personnel will be required to present their donor healthcare facility s picture identification and/or MRC badges at the site designated by the recipient healthcare facility s command center. The recipient healthcare facility will be responsible for the following: a. Meeting the arriving personnel (usually by the recipient healthcare facility s security department or designated entrance). b. Confirming the donated personnel s picture ID badge. c. Providing additional identification, e.g., visiting personnel badge, to the arriving personnel. The recipient healthcare facility will accept the professional credentialing determination of the donor healthcare facility (via MRC) but only for those services for which the personnel are credentialed at the donor healthcare facility. The recipient healthcare facility will notify MHOAC of personnel upon arrival. 3. Demobilization Procedures: The recipient healthcare facility will provide and coordinate any necessary demobilization procedures and post-event stress debriefing. The recipient healthcare facility is responsible for providing the loaned personnel assistance, e.g., transportation, necessary for their return to the donor healthcare facility. Section VII - Page 130 of 138

229 Transfer of Pharmaceuticals, Supplies or Equipment 1. Communication of Requests: The request for the transfer of pharmaceuticals, supplies, or equipment initially can be made verbally to the MHOAC. The request, however, must be followed-up with a written or electronic communication. The recipient healthcare facility will identify to the MHOAC the following: a. The quantity and type of needed items. b. Location to which the supplies should be delivered. The donor healthcare facility will identify if or to what extent the request can be honored and how long it will take them to fulfill the request. Since response time is a central component during a disaster response, decision and implementation should occur quickly. 2. Documentation: The recipient healthcare facility s security office or designee will document and confirm the receipt of the material resources. The documentation will detail the following: a. The items involved. b. The condition of the equipment prior to the loan (if applicable). c. The responsible parties for the received material. The donor healthcare facility is responsible for tracking the borrowed inventory through its standard requisition forms. 3. Transporting of pharmaceuticals, supplies, or equipment: The recipient healthcare facility is responsible for coordinating the transporting of materials both to and from the donor facility. This coordination may involve government and/or private organizations, and the donor facility may also offer transport. The recipient healthcare facility will notify the MHOAC of arrival of donated equipment or supplies. Transfer/Evacuation of Patients 1. This MOU is entered into by and between the healthcare facilities in Placer County to set forth guidelines under which each facility will transfer or accept patients in the event of a Section VII - Page 131 of 138

230 partial or total facility evacuation in an emergency situation. Evacuation of any of the participating healthcare facilities would occur only in extreme emergencies, which would render the participating healthcare facility or a portion of the participating healthcare facility unusable for patient care. (Examples of such situations requiring evacuation and transfer of patients to other healthcare facilities would include but not be limited to a major fire, building damage, environmental hazard, etc.) 2. Agreements: a. Subject to medical capability and space availability, each healthcare facility agrees to accept a transferring facility s emergent patients in the event of an emergency evacuation. b. The receiving healthcare facility will provide applicable medically necessary healthcare services as may be required by patients transported to the receiving healthcare facility. Each of the healthcare facilities will follow its standard procedures for admission of patients and its standard protocols for providing care to patients. c. The transferring healthcare facility will be responsible for arranging for transportation of any evacuated patients to the receiving healthcare facility. The transferring healthcare facility is responsible for arranging transportation of patients from the receiving facility back to the originating facility. d. The transferring healthcare facility will provide the receiving healthcare facility with as much advance notice as possible of any patients requiring evacuation to a receiving healthcare facility by contacting the DCF and activating the MHOAC. The MHOAC, in turn, will notify the Regional Disaster Medical Health Specialist (RDMHS). e. The transferring healthcare facility will send to the receiving healthcare facility at the time of transfer such identifying administrative medical and related information as may be necessary for the proper care of the transferred patient. f. The transferring healthcare facility will send with each patient at the time of transfer (or as soon thereafter as possible) all of the patient s personal effects, and any information relevant thereto. In the event that the personal effects cannot be sent with an alert and competent patient, the transferring healthcare facility Section VII - Page 132 of 138

231 Term and Termination may elect to secure such personal effects until the crisis is over. The transferring healthcare facility will remain responsible for such items until receipt thereof is acknowledged by the receiving healthcare facility. g. This MOU does not require a transferring healthcare facility to transfer patients to any healthcare facility. The transferring healthcare facility may transfer patients to facilities other than healthcare facilities. h. The receiving healthcare facility may discharge patients in accordance with its standard processes. i. The transferring healthcare facility agrees to readmit patients when capability and capacity are restored at the transferring healthcare facility. The receiving healthcare facility agrees to transfer the patients back. As to each participating healthcare facility, the terms of this Agreement will commence on the date this Agreement is approved by the HCEC, and will continue in full force and effect for five (5) years of date of last signatory unless terminated or modified by mutual written agreement by all participating healthcare facilities. An individual facility may elect to terminate its participation in this MOU by providing thirty (30) days written notice to other participating healthcare facilities of its intent to terminate. Section VII - Page 133 of 138

232 IN WITNESS WHEREOF, the undersigned have executed this Agreement on behalf of: HEALTHCARE FACILITY NAME HERE By Authorized Signature Date Title Section VII - Page 134 of 138

233 Patient Charge Capture: Minimum Required Data Elements and Template APPENDIX H Section VII - Page 135 of 138

234 Patient Charge Capture: Minimum Required Data Elements and Template During a disaster scenario current methods of charge capture via electronic systems within existing facilities may be unavailable. Additionally, alternate care sites may lack the infrastructure to accommodate electronic systems and the structure to capture charges. Therefore, paper-based methods for capturing charges may be required in both existing and ACS facilities. Furthermore, it may be reasonable to expect that most healthcare resources will be devoted to patient care. As such, administrative functions under surge conditions may need to be reduced to minimum requirements. The following information recommends a list of minimally required data elements for charge capture. The significance of maintaining accurate charge capture information during surge is that it will allow facilities to properly bill for services, receive reimbursement, and maintain cash flow and business continuity during the event. The following includes a list of recommended minimum data elements required for charge capture during healthcare surge. Sample templates are also included. The forms are not meant to replace existing forms at facilities but rather to serve as samples to consider using during healthcare surge. Acceptance of charge capture elements will ultimately depend on private/government payers agreeing to accept these recommended minimum data elements for billing purposes. Charge Capture Standard Data Elements The following information includes a list of standard charge capture elements. Charge Detail Medical Record Number (For Matching Purposes) Patient Account Number (For Matching Purposes) Service Code (CDM Item Number) Date of Service Posting Date Charge Quantity Posted Charge Charge Description Master Service Code (CDM Item Number) Service Description Medicare HCPCS Additional CPT4 Codes Revenue Code Department Service Price Suggested Minimum Data List The following list was derived from the standard elements list above and includes a recommended list of minimum required data elements: Patient name Medical record number Date of Service (DOS) Capture units/dose/quantity Department services provided in Service description Triage Tag Number The following template serves as a sample for ACS(s) to consider using during healthcare surge and is based on the idea of capturing only minimum required data for charge capture.

235 Unique Patient Identifier (#): Patient Name (Last, First): Provider Name: Triage Tag Number: Service Description Department Units of Service or Quantity Date of Service To be completed by Billing Code: Service / Revenue/ CPT/HCPCS Service Price Posted Charge TOTAL CHARGES

236

237 ACS Equipment & Supply Matrix APPENDIX I Section VII - Page 138 of 138

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239 Page 139 of 238

240 Page 140 of 238