EMERGENCY EVACUATION SAFETY PLAN FOR RESIDENTIAL SUPPORTS

The Emergency Evacuation Safety Plan form has instructions for completing the different elements of the plan.  For expanded guidance on each element of the plan, please refer to the Emergency Evacuation Safety Plan Guidelines Handbook.      

GENERAL INFORMATION

Date of Completion:		
Agency:		
Address of Residential Support:		

Names of Individuals Served At Site (not for site-based respite supports):  

	

Home is owned/rented/leased by the provider		Yes	 Individuals		Yes	

Type of Residential Support  (check the appropriate box and give the # of hours of service provided):

24 Hour Staffed Home		Yes	

Site-Based Respite Support		Yes	

15 to 24 Hour Staffed Home		Yes		# Hours per Week	   Day 	
    
Shared Living (see definition page of Handbook)		Yes		# Hours per Week	
   Day 	

Home Sharing (see definition page of Handbook)		Yes		# Hours per Week	
   Day 	
Type of Building (check the appropriate box and give the number of floor(s) in the building, the floor(s) where bedrooms are located, and the floor(s) that the home occupies):
	
Single Family Home (Freestanding)		Yes		# Floors	
		
Bedrooms located on Floor(s)		

Attached dwelling (Townhouse type)		Yes		# Floors	
		
Bedrooms located on Floor(s)		

2-3 Family Duplex, 2 story, or triple decker		Yes	

Home located on Floor(s)		Bedrooms located on Floor(s)		

Multiple Family (Apart/Condo Bldg. < 5 Stories)		Yes		# Floors in Building	

Home located on Floor(s)		Bedrooms located on Floor(s)		

High Rise (> 5 Stories)		Yes		# Floors in Building	

Home located on Floor(s) 		Bedrooms located on Floor(s)		

ENVIRONMENTAL STANDARDS

Fire Safety Equipment (check the box at right to indicate the types of fire safety equipment present in the home):

Smoke Detection System

Smoke detector(s) located in bedroom(s)							
Interconnected smoke detectors							
Battery operated smoke detectors							
	Alarm system hard-wired to Fire Department or central monitoring station		

      Other Safety Equipment

Fire suppression (sprinkler) system							
Emergency battery-operated lighting							
Automatic door closers								
Fire extinguisher in kitchen								

Other (describe):

SITE FLOOR PLAN

Using page 13 in this document, create a floor plan of each floor of the home accessed by individuals, with each egress clearly marked using the following chart of egress types.  Attach additional pages as needed.

EGRESS TYPES	
a.	Interior Stairs
b.	Elevator
c.	Door to Exterior Stairs to Grade
d.	Door directly to Grade
	e.	Handicap Accessible Ramp
f.	Basement Interior Stairs
g.	Basement Stairs to Grade (Bulkhead Type)
h.	Door to common hallway to egress(s)
i.	Other (describe)	

GENERAL SAFETY REQUIREMENTS

Required only for 24 hour staffed homes that are owned, rented or leased by the Provider and site-based respite supports.  All others skip this section.

All homes providing 24-hour staffed supports and site-based respite supports must meet the following general safety requirements.  Mark the checkbox provided to affirm compliance with the standard.

1.	There are 2 means of egress from floors at grade level and one means of egress and one proven, usable escape route leading to grade for all other floors.

	             Correct

2.	Bedroom doors that provide access to an egress do not have a lock.

	             Correct

3.	Any locks on bedroom doors that do not provide access to an egress:

a.	may be easily opened from the inside without a key and the individual is able to unlock the door from the inside;
b.	staff carry a key to open the door in the event of an emergency.

             Correct
	
4.	Bedrooms of individuals requiring hands on physical assistance to evacuate or who have a mobility impairment are located on a floor at grade level.

		Correct
 
5.	Smoking is prohibited in all bedrooms.

		Correct

6.	Staff do not smoke in the home.

		Correct

7.	Ashtrays of non-combustible material and safe design are provided in all areas where smoking is permitted.

		Correct

	If any individual in the home smokes, answer the following:
	
Location of smoking area:		

8.	All vertical chutes (laundry, dumbwaiter, etc.) are sealed.

		Correct 

PROPOSED ALTERNATIVES

Providers of 24-hour staffed homes are allowed under DDS Regulations 115 CMR 7.07(8) to propose alternatives to the environmental standards and fire safety requirements of 115.CMR 7.07.  This section does not apply to site based respite.  Providers must clearly demonstrate below how the safety of residents is maintained by using the alternative being proposed.

Regulation Standard for which an alternative is proposed:		
Proposed Alternative:		

Why is the standard not needed?  

How does the proposed alternative standard assure that a comparable level of safety is achieved?  

Individual Abilities And Safety Strategies

This section is a summary description of individual characteristics that affect the ability to evacuate the home safely within 2 ½ minutes during an emergency.  This does not replace the need for a thorough assessment of individual skills at the time of the ISP, but rather is taken from those assessments.  Refer to Emergency Evacuation Safety Plan Guidelines Handbook for information helpful in completing this section.  For site-based respite, answer the questions in terms of the abilities of individuals that potentially could be served at the respite home.

Answer the following:

1.	Does the level of ability (cognitive) of any individual prevent or limit their ability to evacuate independently in 2.5 minutes?

	Yes		No

2.	Does any individual have mobility issues that would prevent or limit their ability to evacuate independently in 2.5 minutes?

	Yes		No

3.	Does any individual have health related issues that would prevent or limit their ability to evacuate independently in 2.5 minutes?

	Yes		No

4.	Does any individual have social or behavioral issues that would prevent or limit their ability to evacuate independently in 2.5 minutes?

	Yes		No

5.	Does any individual need adaptive devices or equipment to ensure safe and timely evacuation?

	Yes		No

If all questions above are answered no, SKIP the following chart and go to the section on Group Interactions.  Note: Chart is not completed for site-based respite 

Instructions for completing the chart below:

If any question above is answered yes complete the following chart for all individuals residing in the home.  Add additional pages as needed.

1.	Complete for each individual residing in the home, adding additional pages as needed.

2.	The section on “ability to evacuate” needs to fully address any individual’s cognitive, mobility, health, social or behavioral needs that affect the ability to evacuate.

3.	The section on “staff assistance” needs to fully describe any needed staff assistance and also include the level of assistance provided to evacuate, taken from the following list:

a.	Independent

b.	Verbal Prompt

c.	Physical Prompt (light physical direction)

d.	Physical Escort (actual physical support to evacuate)

e.	Full physical assistance - describe the amount of assistance needed; e.g. two person staff   
      transfer

4.	The section on adaptive equipment needed should describe the specific devices that support evacuation; e.g. bed shakers, flashing strobe lights.

Name:	
Ability to Evacuate (describe cognitive, mobility, health, social, or behavioral needs affecting evacuation)	Staff Assistance Provided (Include level of assistance provided from a - e above)
If adaptive equipment is needed describe specific staff assistance provided	Adaptive Devices/Equipment Needed	

			

Name:	
Ability to Evacuate (describe cognitive, mobility, health, social, or behavioral needs affecting evacuation)	Staff Assistance Provided (Include level of assistance provided from a - e above)
If adaptive equipment is needed describe specific staff assistance provided	Adaptive Devices/Equipment Needed	

Name:	
Ability to Evacuate (describe cognitive, mobility, health, social, or behavioral needs affecting evacuation)	Staff Assistance Provided (Include level of assistance provided from a - e above) 
If adaptive equipment is needed describe specific staff assistance provided	Adaptive Devices/Equipment Needed	

Name:	
Ability to Evacuate (describe cognitive, mobility, health, social, or behavioral needs affecting evacuation)	Staff Assistance Provided (Include level of assistance provided from a - e above) 
If adaptive equipment is needed describe specific staff assistance provided	Adaptive Devices/Equipment Needed	

Name:	
Ability to Evacuate (describe cognitive, mobility, health, social, or behavioral needs affecting evacuation)	Staff Assistance Provided (Include level of assistance provided from a - e above) 
If adaptive equipment is needed describe specific staff assistance provided	Adaptive Devices/Equipment Needed	

GROUP INTERACTIONS

Are there any interactions between individuals being supported or any group dynamics that could affect timely evacuation, either positively or negatively?  (Do not answer for site-based respite.)

		Yes		No

If yes, describe:

EVACUATION PLAN

The evacuation plan incorporates components discussed previously, including individual abilities, group interactions and dynamics, staff responsibilities, adaptive equipment, egresses.

Minimum ratio of staff to individuals during awake hours		
Minimum ratio of staff to individuals during asleep hours		Awake staff		Asleep staff	

Asleep hours are from 		to		

Using a bullet format as needed, answer each of the following evacuation questions, adding additional pages as needed:

1.	Describe the sequence for evacuating all individuals and any staff’s or supporter’s responsibilities.  Include the kind and level of assistance needed for all individuals including staff support with adaptive equipment:

Describe Evacuation Plan During Awake Hours.

Describe Evacuation Plan During Asleep Hours.

2.	State the amount of time needed to safely evacuate all individuals.
	
3.	Identify the primary escape route.

4.	Identify the secondary escape route.

5.	Identify the location of the central meeting place.

FIRE DRILLS

DDS Regulations 115 CMR 7.08 requires that providers of 24-hour staffed homes conduct quarterly fire drills, two of which shall be conducted during nighttime hours.  

Complete the following:

Number of annual fire drills during awake hours:		
Number of annual fire drills during asleep hours:		

Range of hours during which asleep drills will be conducted:		

Do the proposed fire drills differ from the number and schedule required in DDS Regulation 115 CMR 7.08 as described above?		Yes		No	

If the answer is yes, describe the proposed schedule and why it differs from this regulation.  Providers must clearly demonstrate how the safety of residents is maintained by the alternative proposal.  This section should also be used to outline drills for individuals in residential settings other than 24-hour staffed homes and site based respite supports.

METHODS TO NOTIFY POLICE, FIRE, EMERGENCY PERSONNEL, FAMILIES, DMR

Are all staff and individuals, as applicable, aware of procedures for notifying police, fire, emergency personnel, and relevant “on call” staff?		Yes		No	
Who will make the call?		
When and where will the call be made?		
To whom will the call be made?		

What is the protocol for notifying “on call” staff of the provider, families/guardians, and the DMR area office?

TRANSPORATION AND IMMEDIATE/TEMPORARY RESETTLEMENT

	What is the plan for providing immediate shelter (e.g. neighbor’s home) during the emergency?

If the emergency is serious enough to require temporary resettlement, what is the plan?

	How will people be transported to the new location in the event of temporary resettlement?

	Are staff aware of the procedure for temporary resettlement?		Yes		No

CONTINUITY OF SERVICES AND SUPPORTS

If resettlement is required, please describe below how continuity of services and supports will be maintained within the first 24-48 hours after the emergency occurs?

OTHER COMMENTS: (Optional)

Please use this section to include any other relevant information not previously addressed.

Site Floor Plan

Egress Types

a.	Interior Stairs	d. Door Directly to Grade	g. Basement Stairs to Grade (Bulkhead Type)
b.	Elevator	e. Handicap Accessible Ramp	h. Door to Common Hallway to Egress (s)
c.	Door to Exterior Stairs to Grade	f. Basement Interior Stairs	i. Other (describe)

Address: 		

Floor # 		

PROVIDER ASSURANCE FORM
	
       I hereby certify under the pains and penalties of perjury that the home or work/day support

located at                                                      with a capacity of        individuals, and 

operated by                                                 meets or exceeds, or with respect to a new                                 (name of provider)

support, agree to meet or exceed the requirements for assurances of safety as listed below and in accordance with the regulations of the Department of Developmental Services (115 CMR 7.08).

1.	The written Emergency Evacuation Safety Plan includes all the applicable components required in 115 CMR 7.08(3); or the current disaster and evacuation plan will remain in effect.

2.	The Emergency Evacuation Safety Plan is designed for the safety of individuals requiring evacuation in an emergency, is implemented, and is periodically evaluated for effectiveness.

3.	All required fire safety equipment as referenced in the safety plan is functional (i.e., smoke detectors, alarms, adaptive equipment, sprinklers, or emergency back-up systems, if applicable).

4.	The following documentation, as applicable, is available for review:

	a.  Fire Drill log;

	b.  Emergency Evacuation Safety Plan;

	c.  Documentation that each staff person/home provider has been trained in implementation
             of the Emergency Evacuation Safety Plan.
	
Provider:

Signed                                                                 Date:                                     

Print Name & Title:

DDS Area Director:  I have reviewed and approved the Emergency Evacuation Safety Plan as submitted.

Signed                                                                 Date:                                     

Print Name & Title: