CLINICAL Policies and Procedures EMERGENCY PREPAREDNESS Policy #: CP280 BOD Approval/Review NHPCO Standard(s) CES 11, 14.2 03/21/17 Regulatory Citation(s): 45 CFR 164.308(7), COPs 418.113, NYCRR Title 10, Art 9, Section 794.1(m) POLICY High Peaks Hospice & Palliative Care, Inc. (HPHPC), in the event of a disaster, insures that patient needs are met by utilizing an all-hazards approach. This approach includes the management of the consequences of power failures, natural disasters and other emergencies that would affect this hospice's ability to provide care while providing employees a safe working environment. PROCEDURE A. Contact Management 1. A 24/7 emergency contact list including telephone number and e-mail addresses of HPHPC emergency contact persons and alternates will be indicated in the NYSDOH Health Provider Network. (See Personnel Policy Health Commerce System HPH160). 2. A call down list of HPHPC staff will be maintained for each office. Name, personnel telephone number, pager number (if applicable), and home address will be included. The call down list will be updated by Office Managers (OM) at least monthly on the first Tuesday of every month. Any revised lists will be forwarded to each office. 3. A telephone tree will be maintained by the OM for each office as a quick reference for HPHPC staff. 4. A telephone tree of HPHPC Directors will be maintained by the Administration Assistant (AA). Copies will be distributed to each office. 5. Community radio broadcast stations will be identified within the clinical offices' service areas as sources of emergency information should regular means of agency communication be unavailable during an emergency. 6. OMs will maintain a list of all active patients, including telephone numbers; RN Case Managers (CM); physicians; current priority levels related to severity of condition and Transportation Assistance Levels (TAL): a. Patient Classification Levels: Page 1 of 6
1) LEVEL 1 High Priority Includes patients who need uninterrupted services; patients whose condition is highly unstable and where deterioration or inpatient admission is highly probable if the patient is not seen. Examples include patients requiring life sustaining equipment or medication, those needing highly skilled wound care, and unstable patients with no caregiver or informal support to provide care. Every possible effort will be made to see these patients. 2) LEVEL 2 Moderate Priority Includes patients for which services may be postponed with telephone contact; a caregiver can provide basic care until the emergency situation improves. 3) LEVEL 3 Low Priority Includes patients who may be stable and have access to informal resources to help them; a patient can safely miss a scheduled visit if basic care is safely provided by family or other informal support or by the patient personally. b. Transportation Assistance Levels for planned evacuations 1) TAL1 Non-Ambulatory: patient requires transportation by stretcher, backboards, basket litters or other appropriate devices, or rescue-dragged on their mattresses. Clinically unable to be moved in a seated position. 2) TAL2 Wheelchair: Patient is unable to walk due to physical or medical condition. Able to remain seated for prolonged periods and do not require attached medical equipment or medical gas other than oxygen. 3) TAL 3 Ambulatory: patient is able to walk at a reasonable pace the distance to a designated loading area without physical assistance and without any likelihood of resulting harm or impairment B. Planning 1. HPHPC will conduct a hazard vulnerability analysis when the emergency preparedness policy is instituted; making updates any time there is a significant change in the local communities due to a disaster or when a county redoes its Hazard Analysis Report. 2. HPHPC will work with regional or county emergency management planning agencies to: a. Establish priorities among the potential emergencies identified in the hazard vulnerability analysis Report as conducted by NYS Office of Emergency Management (OEM). b. Define HPHPC s role in relation to a community-wide emergency management program. c. Develop an all hazards command structure to facilitate activities in five major functional areas of Command, Operations, Planning, Logistics and Finance/Administration within HPHPC that links with the community command structure as appropriate. d. Establish and document sites for a HPHPC agency-wide temporary command center and sites for temporary centers of operation for the clinical offices. Emergency Preparedness CP280 Page 2 of 6
3. Procedures will describe mitigation, preparedness, response and recovery strategies, actions, and responsibilities 4. Staff preparedness includes but is not limited to: a. Transportation resources identified for inclement weather. b. Knowledge of Emergency/Disaster Procedures for specific localities. c. Emergency kits for office supplies, patient care supplies and staff supplies. d. Car adapters for computers. e. Radio access information 5. HPHPC will regularly test, document and critique its emergency management plan at each site included in the plan using realistic scenarios related to the priority emergencies defined by leadership that are likely to affect continuation of care, treatment or services. a. The process will include administrative, clinical and support staff. HPHPC will evaluate its handling of communications, resources and assets, staff and patients. b. Documentation will identify the effectiveness of HPHPC preparedness, mitigation, response and recovery activities. c. Noted deficiencies and opportunities for improvement will be addressed. d. The evaluation process will also be followed during and after an actual emergency. 6. Modifications of the emergency management plan in response to the critiques of the test or actual emergency event will prioritize processes identified for improvement, and institute plans for improvement. a. The next planned exercise will evaluate the effectiveness of the improvements made in response to the critiques. b. If improvements require substantial resources and cannot be accomplished by the next planned exercise, interim improvements must be put in place until final resolution. 7. Emergency management education will be provided to all HPHPC staff during initial orientation and annually thereafter, including: a. Specifics of HPHPC s emergency management plan b. Information on developing their family s emergency response plan c. The role the employee will play in an emergency situation d. Information regarding accessing housing and transportation for staff if necessary C. Plan Implementation 1. At the time of admission, patients and family/caregivers will be given information regarding emergency management and their personal responsibilities as outlined Emergency Preparedness CP280 Page 3 of 6
in the Patient/Family Emergency Planning Resource Guide, the Special Needs Registry, and Reverse 911- if available in their area. a. At the initial comprehensive visit, the social worker will assess the patient and family/caregivers' emergency management plan. b. Any special needs will be noted in the plan of care, to be updated as needed. 2. Patient and HPHPC staff safety will take priority in all emergency situations. a. Staff will be supported when the emergency may affect them directly. The impact of the disaster on a staff member will be assessed and considered in the planning of the event response and accommodations made as necessary. b. Examples of conditions monitored include weather/road conditions via local weather and state patrol reports; natural or community disasters via the Emergency Broadcasting System, reports from local authorities, reports from other local healthcare facilities in the event there is no telephone communication. 3. The decision to activate the emergency management plan will be made by the Executive Director (ED) or designee. The decision to discontinue or terminate the emergency management plan operations will be made by the ED or designee. 4. HPHPC Incident Command site(s) will be designated in the event the offices are evacuated or not accessible. a. The ED or designee will notify staff and the appropriate community authorities. b. An HPHPC incident command center log will note staff availability and those staff members who cannot be contacted. 5. HPHPC staff are to report to their designated office or alternate site to receive instruction if they are able. If unable they must contact their supervisor. a. The ED or designee will assign a duty roster of responsibilities by staff discipline and functional areas. b. Clinical and financial records will be maintained. c. Necessary blank documentation forms will be available. d. Electronic records are to be backed up as possible. e. The IT Specialist or designee will assess the communication systems. f. The Chief Financial Officer (CFO) or designee will monitor the cost and time reports during the emergency disaster. g. The ED or designee at the Incident Command Structure will maintain communications and act as the spokesperson among other facilities, media, and community and safety authorities. 6. Staff unable to communicate with the HPHPC incident command center(s) should listen to the appropriate radio station for HPHPC instructions and updates. Emergency Preparedness CP280 Page 4 of 6
D. Patient Care 1. If a disaster is anticipated, such as a weather related event, RN CMs should call assigned patients/caregivers prior to the event to prepare individuals and determine if extra supplies are needed. 2. If an event occurs without warning, RN CMs will call assigned patients and caregivers to determine needs. 3. Verbal report of changes should be made through the communication chain to the appropriate person(s) e.g. Patient Care Coordinator (PCC), Triage RN, On Call, and to the Incident Command Center. 4. If necessary, Durable Medical Equipment (DME) vendors will be provided reports from the HPHPC Incident Command Center. 5. If feasible, the PCCs will assign available, qualified personnel to care for Level 1 patients first and Level 2 patients second. a. If care cannot be provided to Level 1 patients, emergency transport to alternate care delivery sites will be arranged with community support agencies. b. Safe transportation to get staff to a patient's home will be arranged via county support services, such as the police, fire, or sheriff s office 6. Level 3 patients will be contacted as soon as possible. Facilities housing HPHPC patients will be contacted to coordinate actions/services for hospice patients. 7. Clinical staff will communicate the outcome of patient visits to the Incident Command Center. 8. Visit documentation will be entered into patient charts when staff are able. 9. New patients will not be accepted for care until the emergency situation is controlled or staffing levels permit. Patients accepted, but not yet admitted, will be triaged as noted above. 10. If a community experiences an epidemic or infection, HPHPC will not accept or treat infected patients unless a management plan has been implemented for an influx of potentially infectious patients over an extended time. 11. Disclosure of protected health information (PHI) follows current HIPAA, state and federal guidelines. PHI disclosures may be made to entities involved in disaster relief activities including government agencies and private disaster assistance/relief organizations authorized by law or organizational charter to assist in disaster relief efforts. Emergency Preparedness CP280 Page 5 of 6
12. In the event of a prolonged emergency situation, the ED or designee will: a. Determine staffing availability and limitations, including assistance available from external staffing agencies b. Determine course of action based on above information c. Identify patients with continuing care needs d. Contact other area hospice organizations to determine degree to which they may be able to accept new patients, if the decision is made to transfer. e. Notify attending physicians regarding ability to continue caring for patients E. Emergency After Working Hours 1. On Call staff will take information and notify the On Call PCC. The On Call PCC will immediately notify the ED or designee. 2. The ED or designee will evaluate the extent of the disaster and determine whether or not to implement HPHPC s Emergency Preparedness Plan. a. If the plan is to be activated, staff will be notified via email or telephone tree. b. Based on the incident, available and qualified personnel will be mobilized to perform identified services as deemed necessary from the Incident Command Center. 3. Established emergency procedures will be followed. LAST REVIEW DATE: ED 04/28/15, IDT 11/9/16, Clinical Comm 12/6/16 LAST UPDATED: Comp Coor 11/18/16, 12/12/16, 04/12/17 BOARD APPROVAL: March 21, 2017 Emergency Preparedness CP280 Page 6 of 6