The Commonwealth of Massachusetts

Executive Office of Health and Human Services
Department of Public Health
Division of Health Care Quality
99 Chauncy Street, 2nd Floor, Boston, MA 02111
617-753-8000

MITT ROMNEY
GOVERNOR
KERRY HEALEY
LIEUTENANT GOVERNOR
TIMOTHY R. MURPHY
SECRETARY
PAUL J. COTE, JR.
COMMISSIONER	

CIRCULAR LETTER:  DHCQ  06-4-459

TO:		Long Term Care Facilities Administrators

FROM:	Paul I. Dreyer, Ph.D, Associate Commissioner 

DATE:		May 5, 2006

RE:		Attestation for Continuity of Operations Plans (COOPs) 

The purpose of this letter is to inform all licensed nursing and rest homes of their obligation to ensure the continued delivery of services to their residents clients in the event of an influenza pandemic or other long-term emergency.  As part of their responsibility to have detailed plans and procedures to meet all potential emergencies, providers have been instructed to develop an agency-specific Continuity of Operations Plan (COOP) to augment existing emergency preparedness plans already in place.  

In keeping with the Department’s goals regarding pandemic planning, the Division of Health Care Quality is now seeking to confirm your compliance with COOP development.   Enclosed you will find a 3-page document consisting of an Attestation that the facility has developed a COOP as required, a short self-evaluation tool regarding your COOP’s content, and a section to itemize any remaining questions or concerns you may have.

Please sign and date the Attestation and complete the evaluation tool.  Return the signed and completed document to the Division no later than Monday, May 22, 2006.   

Please do not send in your actual COOP at this time.

Mail or fax completed document to:	

Department of Public Health
Division of Health Care Quality
99 Chauncy St., 3rd Floor
Boston, MA  02111
Fax: (617) 753-8094  (Attention: Deirdre Hanniffy)

If you have any questions, please refer to the Department’s website for COOP planning for answers to Frequently Asked Questions and other information that may provide clarification at:
	
www.mass.gov/hhs/coop

If questions or concerns remain, please document them on the evaluation form, or as an addendum to the form, and return it to the Division with the Attestation.  Questions may also be sent via fax to Deirdre Hanniffy at 617-753-8094, or you may e-mail the Continuity of Operation Plans team at EOHHS at:

POS.COOP@ehs.state.ma.us.
	
In an effort to provide accurate and consistent information, all questions directed to the Division will be compiled and reviewed with representatives from the Commissioner’s office and responses will be distributed as soon as possible.

Attachments:
•	Provider Review Tool for Continuity of Operations Plans
•	Attestation of compliance

Provider Review Tool
Continuity of Operations Plan (COOP)

Facility Name:	_______________________________________________________________________	
Town:	_____________________________________________________	
Name of person completing form:	________________________________________________	Title:	____________________________	

Attestation:

The undersigned representative(s) of the provider hereby attest that, pursuant to the facility’s responsibility to ensure the continuation of essential services of the Commonwealth, the provider has developed a Continuity of Operations Plan that addresses each of the essential elements of a COOP, as described below. 

__________________________________________	_____________________________________	_______________	
Name and Title (please print)	Signature	Date	
			
__________________________________________	_____________________________________	_______________	
Name and Title (please print)	Signature	Date	
			
__________________________________________	_____________________________________	_______________	
Name and Title (please print)	Signature	Date	

Purpose
The Continuity of Operations Plan (COOP) provides policy and guidance to ensure the execution of essential functions in the event that agency operations are threatened.  A COOP identifies essential services, agency leads, delegations of authority, and other key pieces of information critical to the maintenance of services during an extended emergency.  

COOP Event:  Emergencies or potential emergencies that may affect a department or agency’s ability to carry out its essential functions, such as, but not limited to: epidemics or pandemic disease; natural disasters such as floods, earthquakes or tornados; terror attacks, or related emergency events.	

For more information, including answers to frequently asked questions about COOP planning, please refer to the Department’s website at:  www.mass.gov/hhs/coop

Elements of the COOP
ELEMENT	Yes/No	
•	Activation/Deactivation Criteria: 	
1.	Criteria for COOP activation (ex., governor declares state of emergency, etc)	 Yes   No	
2.	Criteria for COOP deactivation (ex., staffing levels have returned to normal)	 Yes   No	
•	Plan Developer: 	
3.	Name and title of individual identified as responsible for the development of a viable and executable COOP for the facility.	
	________________________________________________ 	  _________________________________________
	Name	Title	 Yes   No	
•	Essential Functions: 	
	4.	Plan identifies and prioritizes essential functions necessary for agency continuity of operations.  	 Yes   No	
		Essential functions include services that are:		
•	Life sustaining
•	Protective/Investigative	•	Emergency Medical
•	Food and Shelter	•	Critical Ancillary Providers
•	24/7 Direct Care Providers		
•	Order of Succession: 	
	5.	There is an order of succession for each essential function.  	 Yes   No	
	5a.	The list includes each successor’s:	 Yes   No	
•	Name and title
•	Work, cell and home telephone numbers
•	Other available methods of contact, including pagers, e-mail, etc.		
•	Delegation of Authority: 	
	6.	There is a delegation of authority for each essential function.  	 Yes   No	
	6a.	The delegation of authority includes:	 Yes   No	
•	Source of the authority being delegated (position title and/or source)
•	Name and title of incumbent being delegated the authority
•	Work, cell and home telephone numbers
•	Other available methods of contact, including pagers, e-mail, etc.
•	Authorities delegated, together with any limitations on, or exceptions to, their use
•	Name, title and signature of the official empowered to delegate the authority specified		
•	Communication Plans: 	
	7.	The COOP includes communication plans for:	 Yes   No	
•	Public relations
•	Clients	•	Staff and other service providers
•	Phone systems		
•	Pandemic Preparation: 	
	8.	The COOP includes preparation for pandemic, such as:	 Yes   No	
•	Dissemination of flu information by means of mail, internet, and other methods
•	Develop and inventory of tasks for critical functions to ease transition of staff performing such functions on behalf of absent colleagues
•	Train successors and delegates identified for essential functions
•	Update contact information for all staff		
•	Direct Care 24/7 Facilities: 	
	9.	Facilities providing 24/7 direct care must, at this point, include a plan for:	 Yes   No	
•	Communications
•	Staffing:  Plan for 40% reduction in staff
•	Infection control for 30% residents ill with flu	•	Medical assessment for 30% residents ill with flu
•	Medication & food:  Plan to provide a supply of each for 30 days

		
•	Personnel Responsibilities: 	
	10.	Responsibilities:  The Plan identifies responsibilities for the following personnel during activation of the COOP:	 Yes   No	
•	Senior Management personnel	•	Professional personnel
•	Administrative personnel	•	Support personnel
•	Contract personnel		
•	Training and Exercises: 	
	11.	The Plan includes a program of training and exercises to evaluate the COOP.	 Yes   No	
	11a.	Tests, training and exercises are planned regularly or at least once yearly to evaluate the COOP and improve the ability of the agency/organization to execute the COOP effectively.	 Yes   No	
	11b.	Testing includes plans for:	 Yes   No	
•	Individual and team training of agency COOP staff and emergency personnel to ensure currency of knowledge and integration of skills necessary for plan execution; 
•	Internal agency testing of COOP plans and procedures to ensure the ability of the agency to perform essential and mission critical functions; 
•	Testing of alert and notification procedures and systems; 
•	Joint agency exercising of COOP plans, where applicable and feasible		
•	Needs Assessment: 	
12.	In developing the COOP, have you identified any areas of vulnerability, questions or issues for which you require further information or clarification?  
	If YES, please itemize and elaborate below*.  
*In order to provide accurate and consistent information, questions will be collected and reviewed with representatives of the Commissioner’s office and answers will be distributed/posted as soon as possible.
Questions may also be e-mailed to the Continuity of Operations Plan team at: 
				POS.COOP@ehs.state.ma.us. 	 Yes   No	

References