ALL HAZARD EMERGENCY PLANNING
LTC Facility Survey Guidance and Provider Attestation Tool

Instructions to Surveyors: 

(Please remove this cover page before giving the attestation to the administrator.)

At the Entrance Conference, give the LTC Emergency Preparedness Provider Attestation tool to the Administrator and ask him/her to complete the document and sign the attestation.  Instruct the provider to return the document to the Team Coordinator before the end of the survey.

During the survey, observe or otherwise obtain evidence to verify the provider’s compliance with the following elements of an Emergency Preparedness plan:

•	Observe evidence of:
•	Plan was developed with assistance of local and state fire and safety experts1
•	Disaster Feeding plan is written3
•	Plans posted as required:
•	All Hazard Emergency plan posted at nurses’/attendants’ station(s) and other conspicuous locations1
•	Disaster Feeding plan posted in kitchen3
•	Food supplies as required (1 week staples, 48 hours perishables)11
•	Plan to ensure water is available to essential areas when loss of water occurs12, including: 
•	Source of emergency water12
•	Storage of emergency water (potable/non-potable)12 
•	Method for estimating volume of water required12 (potable/non-potable)(generally 1 gal per person per day)27

•	Confirm through interview:
•	Staff knowledge of generator-powered systems24
•	Staff knowledge of emergency procedures for various situations24, 25
•	Training by local fire department24, 25
•	Staff familiarity with Disaster Feeding Plan3

Cover Page: Instructions for Survey Team
ALL HAZARD EMERGENCY PLANNING
LTC Facility Provider Attestation

Directions: Administrator, Please complete and sign this attestation.  Check each item that applies and is included in this facility’s emergency plan. Return the completed signed form to the Survey Team Coordinator by the end of the second day of survey. 

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 at the above-named facility, the provider has developed an All Hazard Emergency Plan that addresses, at a minimum, each of the essential elements described below. 
	
___________________________________	_______________________________	__________________	
Name and Title (Please print)	Signature	Date	

The Plan addresses the following elements:	
•	General:	Comments	
•	Plan is written,4,7
•	Plan developed with assistance of local & state fire and safety experts1
•	Plan addresses:
•	Building security (access, crowd control, traffic control, etc)
•	Processes & persons to be notified8  (staff, external authorities) 
•	Locations of alarm signals8 
•	Plan includes a written transfer agreement with one or more hospitals
•	The Emergency/All Hazards Plan is posted at nurses’/attendants’ stations and other conspicuous locations.1,8
•	The Disaster Feeding Plan is posted in the kitchen.		
•	Hazards: 		
•	The plan addresses1, procedures for mitigation, preparedness, response and recovery strategies, for each of the following hazards, at a minimum: 		
•	Fire in the facility
•	Fire in the community
•	Power outage in the facility
•	Power outage – regional
•	Epidemic in facility
•	Epidemic/pandemic in community	•	Hurricane
•	Tornado                    
•	Earthquake
•	Flooding             
•	Heavy snow/blizzard
•	Missing residents4		
•	Hazard Vulnerability Analysis (HVA):  Facility conducted an HVA to identify emergencies which are potential threats to this specific facility and has developed relevant plans.		
•	Sheltering-in-Place and Evacuation:		
•	Procedure for sheltering residents-in-place 		
•	Evacuation procedures address relocating residents and staff: 7,		
•	within the building
•	outside the community	•	outside the facility but within the community		
•	Evacuation procedures address:
•	Evacuation routes8 
•	Transportation (residents, staff, equipment)
•	Transferring necessities between sites (food, meds, medical records) 
•	Tracking residents
•	Inter-facility communications between facility and alternate care site		
•	Continuity of Operations Plan (COOP):		
•	Continuity of Operations Plan (COOP) in place that:
•	Identifies essential functions necessary for facility continuity of operations.
•	Identifies order of succession for each essential function, with each individual’s contact information and:
•	Assigns specific tasks & responsibilities to personnel of each shift8
•	Ensures personnel are trained to perform assigned tasks  
•	Specifies delegation of authority for each essential function.
•	Includes “Information Technology” (IT) as essential function.
•	Includes communication plans.		
•	Disaster Feeding Plan:		
•	Facility has a written Disaster Feeding Plan which addresses: 
•	Alternate methods for:
•	when equipment is not operable3
•	sanitation of dishes and utensils3
•	hand washing
•	Ability of supplier(s) to meet needs in a regional emergency
•	Cooperation/resource sharing with area facilities/agencies		
•	Facility has supplies of:
•	staple foods for minimum 1-week period
•	perishable foods for a minimum of 48 hours		
•	Water Supply:	
•	Plan ensures water is available to essential areas when loss of water occurs		
•	Plan addresses12:
•	Source of emergency water12
•	Storage of emergency water (potable/non-potable)12 
•	Method for estimating volume of water required (potable/non-potable)12  (generally 1 gal per person per day potable)27
•	Ability of supplier(s) to meet needs in a regional emergency 
•	Cooperation/resource sharing with area facilities/agencies		
•	
Essential Medical/Nursing Supplies:	
•	Oxygen:
•	Plan addresses O2 use/needs during emergency or evacuation and O2  is properly stored on–site.   		
•	Medications:
•	Plan addresses managing medications during an emergency or evacuation, including:
•	Transferring medications during an evacuation 
•	Obtaining medications when sheltering-in-place
•	Ability of supplier(s) to meet  medication needs in an emergency		
•	Other Supplies:
•	Resident supplies (incontinent briefs, medical/nursing supplies, etc.)
•	Personal protective equipment (special clothing barriers, gowns, masks, gloves, breathing/respiratory devices, etc.)
•	Reserve supply of linen		
•	Environment, Equipment & Supplies:	
•	Backup Equipment:  Plan identifies backup equipment and tools and a system to maintain these in working condition (e.g., flashlights, batteries, (NOAA radios, etc.) 		
•	Plan addresses:
•	Management of ventilation system16 in event of emergency that compromises air quality (e.g., fire, chemical cloud, etc.)
•	At least one staff person on each shift trained to shut-down or modify ventilation system if necessary
•	Management of trash, soiled linen and waste material,, 
•	Alternative means for hand washing
•	Fire extinguishers and location of alarms8		
•	Generator:
•	If facility has a generator:
•	The plan addresses:
•	systems the generator will power
•	use of emergency outlets in resident rooms and critical common areas
•	generator fuel
•	maintaining system to start in ≤ 10 sec,,  
•	Staff know what systems & outlets the generator powers 		
•	If facility does not have a generator, plan addresses:
•	Illumination in resident rooms/critical common areas
•	Essential backup equipment to be on-hand and maintained in working order in event of power failure (e.g., flashlights, batteries, radio, cell phones, blankets, means to stay warm/cool, etc)16

•	Physical Plant:	
•	There is a written preventative maintenance program in effect for maintaining, testing, and inspecting the following physical Plant systems in reliable operating condition16,21,22,23:		
•	fire alarm system
•	emergency electrical system (generator)
•	elevators
•	medical gas system
•	portable fire extinguishers	•	battery powered emergency lights (if provided)
•	heating system
•	air conditioning system
•	cooking equipment
•	automatic sprinkler system
		
•	Training:	
•	Personnel trained to perform assigned tasks9: 
•	New employees trained in emergency procedures when begin work in facility 
•	Emergency procedures periodically reviewed with existing staff24
•	Unannounced, simulated drills using emergency procedures conducted at least twice a year, on all shifts, to test Plan’s effectiveness24,  		
•	At least once a year, employees are instructed by head of local fire department in their duties in case of fire, and training is noted in facility’s records  		
•	Staff are familiar with the Disaster Feeding Plan3		
•	Facility has provided training to assist staff in developing a personal (family) emergency preparedness plan.		

References