January 5, 2010

1

Review of Emergency Operations Plan Tasks and Citations

Tips & tools for creating your plan and avoiding deficiencies

January 5, 2010

2Review

Federal Requirements (4 tags) Expectations Citations for 2009 (6/15/09-12/15/09)

Resources

Federal Requirements

January 5, 2010

41 Emergency Plans

F517 §483.75(m)(1) The facility must have

detailed written plans and procedures to meet all potential emergencies and disasters, such as fire, severe weather, and missing residents.

January 5, 2010

52 Emergency Training

F518 §483.75(m)(2) The facilities must train all employees in emergency procedures when they begin to work in the facility, periodically review the procedures with existing staff, and carry out unannounced staff drills using those procedures.

January 5, 2010

63 Emergency Water

F466 The facility must §483.70(h)(1) Establish procedures to

ensure that water is available to essential areas when there is a loss of normal water supply.

January 5, 2010

7

4 Emergency Power

F455 §483.70(b) Emergency Power (1) An emergency electrical power system

must supply power adequate at least for lighting all entrances and exits; equipment to maintain the fire detection, alarm, and extinguishing systems; and life support systems in the event the normal electrical supply is interrupted.

Pictures can also be presented more dramatically in widescreen.

Surveyor Expectations

January 5, 2010

91 Emergency Plans F517

Surveyor Expectations:(1) Plans are easy to find; located multiple places(2) All contact lists are complete and current(3) Facility has identified all potential emergencies and

disasters, based on geographic area and residents(4) Facility has specific procedures for missing

residents, fire, severe weather, and mass casualty/mass care

(5) Have disaster agreements with other facilities that are specific in nature (1)

January 5, 2010

102 Emergency Training F518

Surveyor Expectations:(1) Records review shows staff at all levels are

being trained on an ongoing basis(2) Records review shows plan is being

exercised and evaluated(3) Minimum one drill a year that is a non-fire

drill(4) Staff can answer basic questions related to

training

January 5, 2010

113 Emergency Water F466

Surveyor Expectations (for potable and non-potable):

(1) Plan review includes the sources of your water supply

(2) There is adequate storage for water(3) Plan review includes method for determining

how much water is needed for an emergency (4) Plan includes how water will be distributed

January 5, 2010

124 Emergency Power F455

Surveyor Expectations:(1) Emergency lighting is on hand and provides

sufficient light(2) Staff know how to locate flashlights(3) Staff know how to locate batteries(4) Flashlight is operable

Citations

January 5, 2010

14

F517, Emergency Plans: 10 citations, S/S all level F

F518, Emergency Training: 16 citations, S/S all level F

F 466, Emergency Water: 7 citations, S/S all level F

F 455, Emergency Power: 0 citations for health surveys; 30 citations for Life Safety Code Tag K-144

Citations Issued Between 6/15/09 – 12/15/09

January 5, 2010

151 Emergency Plans F517

(1) Failed to include current emergency telephone lists in emergency plan (manuals out-of-date, missing contact info for key staff (2)

(2) Failed to tailor their emergency plan to its geographic location (7)

(3) Failed to have emergency plans for a mass casualty/mass care situation (1)

(4) Failed to have emergency plans for missing residents (2)(5) Failed to have disaster agreements with other facilities

that are specific in nature (1)

January 5, 2010

162 Emergency Training F518

(1) Failed to provide training for staff on emergencies identified in the facility’s hazard analysis (11)

(2) Failed to conduct emergency training drills for other than fire emergencies (4)

(3) Failed to carry out unannounced drills for facility staff (2)(4) Failed to provide training on the location of the

emergency electrical outlets (1)

January 5, 2010

173 Emergency Water F466

(1) Failed to provide written policy for distributing water (7)(2) Failed to provide written policy defining method of

estimating the amount of water (6) (3) Failed to establish provisions for storing water (5)(4) Failed to establish location/source of water supply (3)(5) Failed to establish method of acquiring non-potable water

(2)

(6) Failed to establish method of water delivery to facility (2)

January 5, 2010

184 Emergency Power 455

(1) Zero cites under F455, under “health surveys (2) Most frequently cited under LSC survey Tag

K-144, for not maintaining generator Facility failed to properly maintain and test

the emergency power source

Resources

January 5, 2010

20

Resources

List From Web Site: www.healthfacilities.info ; on homepage under Emergency Preparedness Planning

Hazard Analysis Toolkit http://www.cdphe.state.co.us/hf/emergencyplanning/hazardanalysis/HazardAnalysisToolkit.doc

Basic Plan Toolkithttp://www.cdphe.state.co.us/hf/emergencyplanning/basicplan/BasicPlanToolkit.doc

Annexes Toolkit –How to Evacuatehttp://www.cdphe.state.co.us/hf/emergencyplanning/evacuation/EvacuationFunctionalAnnexDevelopmentToolkit.doc

January 5, 2010

21

Resources (continued)

Shelter-in-Place Toolkithttp://www.cdphe.state.co.us/hf/emergencyplanning/shelterinplace.html

Mass Care Toolkithttp://www.cdphe.state.co.us/hf/emergencyplanning/masscare.html

Hazard-Specific Toolkithttp://www.cdphe.state.co.us/hf/emergencyplanning/hazardspecific.html

January 5, 2010

22

Resources For YouWe have posted lots of resources to help you.

January 5, 2010

23Contact Information

Melanie Roth, mroth@cdphe.state.co.us or 303-692-2819Your local emergency manager