Topic / Disaster plan / Last Review Date / 06/19/16
CARF Standards / 1.H.2; 1.H.4.b.(3-4), 1.H.5-8 / Last Revision Date / 04/15/14
Purpose / To ensure that staff know procedures to keep themselves and others safe in non-clinical emergency situations
1. Competency-based training:
a. All staff receive competency-based training in emergency procedures at hire and annually thereafter.
b. Staff must score at least 80% on a written test to demonstrate competency.
c. Written test results are maintained in each staff’s personnel file.
2. Evacuation drills:
a. All staff whose positions are office-based or staff who provide office-based therapy on a weekly basis participate in unannounced physical evacuation drills annually.
b. Program Managers at each site complete an evaluation of participants’ competency in the evacuation procedures following each drill.
c. Staff who are not able to demonstrate competency during the drill will be required to participate in retraining and additional evacuation drills until competency is demonstrated.
3. Emergency Procedures, including the evacuation plan and emergency phone numbers (e.g., 911, police department, fire department, poison control, landlord, power company), contain instructions in both English and Spanish and are posted near the main exit door for each office suite. Printed emergency procedures are portable (e.g., easily removed to take with staff when evacuating).
4. Procedures for FIRST AID:
a. The Program Manager or other designated individual in each office location is certified in first aid. This certification is maintained as specified by the certification authority.
b. Each office contains a first aid kit that is inspected and replenished semi-annually by the Program Manager or other designated individual.
c. Emergency and poison control phone numbers are listed on the posted Emergency Procedures.
d. Minor injuries may be treated by any staff trained in first aid. Handwashing is required before and after first aid. Major injuries or life threatening situations (see Medical Emergencies) are handled by calling 911 and following the directions of the emergency professionals.
e. The Program Manager or other designated responsible person completes an Incident Report and notifies the Executive Director of the situation.
5. Procedures for EVACUATION:
a. Evacuation diagrams and instructions are printed on the Emergency Procedures posted in each office location, near the main exit door.
b. Each staff is responsible for guiding their clients or guests through the evacuation process, if a drill or actual emergency occurs when they are in the office.
c. The Program Manager or other designated responsible individual ensures that all staff, clients, and guests have evacuated before leaving the office. The Program Manager takes the posted Emergency Procedures down and carries it during the evacuation.
d. After evacuating, all individuals meet in the location designated on the evacuation plan. The Program Manager or other designated responsible individual checks to ensure that all individuals that were present in the office have been accounted for.
e. When evacuating, staff & guests use the stairs only and not the elevators.
f. If staff is at a home performing services, they will evacuate the home through the nearest exit. Staff at schools will follow the procedures designated by the campus safety officer.
g. Staff, clients, and guests may return to the office after the emergency response professionals (e.g., police, fire department) indicate that it is safe to do so.
h. The Program Manager or other designated responsible person completes an Incident Report and notifies the Executive Director of the situation.
6. Procedures for FIRES:
a. All staff are trained and must demonstrate competency on the location of the fire extinguishers and fire alarms in each office location. This is required at hire and annually thereafter.
b. If a small fire is visible and is judged to be manageable, the first staff to see the fire attempts to extinguish it with the fire extinguisher located in the office.
c. If a fire is judged to be unmanageable or attempts to extinguish it fail, the first staff to see the fire is responsible for pulling the building’s fire alarm and for calling 911.
d. All staff must evacuate the building if the fire alarm is activated or if an unmanageable fire is visible.
e. The Program Manager or other designated responsible person completes an Incident Report and notifies the Executive Director of the situation.
7. Procedures for EXPLOSIONS, GAS LEAKS, & CHEMICAL SPILLS
a. In the event of an explosion, staff and visitors evacuate the building. The Program Manager or other designated responsible person calls 911, notifies the Executive Director, and completes an Incident Report.
b. The agency offices and buildings do not have natural gas lines, so there is no risk of gas leaks in the offices. When providing services in homes with a gas leak, the staff evacuates the house and completes an Incident Report.
c. Hazardous chemicals are prohibited in agency offices. When providing services in homes with a hazardous chemical spill, the staff evacuates the house and completes an Incident Report.
8. Procedures for BOMB THREATS:
a. In the event that a bomb threat is made, the staff receiving the call will attempt to get as much information as possible from the caller, including detonation time and demands.
b. The staff immediately calls 911. If recommended by the 911 officials, the staff notifies other tenants in the building then evacuates the building.
c. Do not pull the fire alarm, as this may detonate the bomb.
d. When bomb squad arrives, the staff who spoke with the bomb threat caller reports known information to them.
e. The staff who spoke with the bomb threat caller is responsible for reporting the threat to their Program Manager and completes an Incident Report.
f. The Program Manager or other designated responsible person notifies the Executive Director.
9. Procedures for natural disasters:
a. Natural disasters include any kind of weather issue that may cause damage to property or harm to life (e.g., tornado, hurricane, severe storm, flood).
b. Local radio stations are played throughout the day in each office location. If the radio indicates an impending natural disaster, staff check the National Weather Service and take precautions as directed.
c. If government offices announce that they are closing, staff cease work and prepare the office for the storm. Storm preparation includes covering all computer equipment with plastic bags and moving CPU’s from the floor onto a desk, unplugging all electronics and moving them as far away from windows as possible. If a warning is issued after hours, Program Managers are be expected to report to work for a short time to prepare the office and then return home to prepare for their own safety.
d. After the storm has passed and the NWS reports that it is safe to drive, Program Managers report to their respective offices to assess for damage and power outages, then contact the Executive Director to discuss resuming office operation. Once a decision is made regarding resuming office operation, Program Managers contact all office staff to inform them of this decision.
e. Clinicians contact their Program Manager if they cannot deliver services. Clinicians also contact their clients to check on their safety and discuss when to continue services.
f. In the case that immediate shelter is required the staff and guests report to the designated “Safe Zone” as indicated on the evacuation plan. The “Safe Zone” is a room with no windows, either within the office suite or within the exterior walls of the building. If a staff is at a home performing services during a natural disaster, they proceed to a room with no windows in the center of the home. Staff located at schools follow the procedures designated by the campus safety officer.
10. Procedures for utility failures:
a. In the event of a power outage, the Program Manager at each location calls the local power company to report the outage.
b. All offices have a source of natural light that illuminates common areas and corridors outside of each room. If any room does not open to an area with natural lighting, staff will keep a cell phone or flashlight with him/her in case of power outage while using this room.
c. If power remains out for 15 minutes during a session with a client, the clinician should cancel the session and reschedule.
d. In the event of a power outage of more than 60 minutes, the Program Manager contacts the Executive Director for further instructions as to relocation or shut down.
e. The Executive Director stores the cell phone numbers for all Program Managers in his/her cellular phone. Program Managers store the personal phone contact numbers for all office staff in their location in their cellular phone. Program Managers are responsible for notifying all office staff in their location of the status of office closure/reopen status and relocation plans, if necessary.
f. In the event of a power outage in an office location for more than two business days, the Executive Director notifies the Program Manager to relocate business functions and office staff to the nearest agency office that has power. Relocation involves gathering equipment and materials needed to perform job functions from the affected office and transporting them to the temporary office location.
11. Procedures for medical emergencies:
a. In the event of a medical emergency that cannot be treated with basic first aid, the nearest staff calls 911 and follows the instructions given by 911 operator until paramedics arrive.
b. The next closest staff accesses the injured party’s emergency contact person’s information. Client’s emergency information is located on the Client Information Sheet in the Client Record. Staff’s emergency information is contained in the Staff Database.
c. The staff handling the medical emergency notifies the Program Manager and completes an Incident Report.
d. If the individual with the medical emergency is a client, the Primary Clinician develops a Personal Safety Plan with the client.
12. Procedures for violent or threatening situations:
a. All staff are trained in verbal de-escalation upon hire and annually thereafter. If a client or other person present becomes violent or threatening, the staff use de-escalation strategies (see Clinical Emergencies).
b. If verbal de-escalation is unsuccessful and violent/threatening continues, the staff calls 911.
13. Essential services: There are no essential services provided by the agency.
1.H.2.a / The organization implements procedures to promote the safety of persons served / Promoting Health & Safety, Infection Prevention & Control, Hazardous Materials, Substance Use & Weapons, Disaster Plan, Clinical Emergencies, Drug-Free Workplace1.H.2.b / The implements procedures to promote the safety of personnel / Promoting Health & Safety, Infection Prevention & Control, Hazardous Materials, Substance Use & Weapons, Disaster Plan, Clinical Emergencies, Drug-Free Workplace
1.H.4.b.(3) / Personnel receive documented competency-based training in emergency procedures / Disaster Plan, Staff Training
1.H.4.b.(4) / Personnel receive documented competency-based training in evacuation procedures, if appropriate / Disaster Plan, Staff Training
1.H.5.a.(1) / There are written emergency procedures for fires / Disaster plan
1.H.5.a.(2) / There are written emergency procedures for bomb threats / Disaster plan
1.H.5.a.(3) / There are written emergency procedures for natural disasters / Disaster plan
1.H.5.a.(4) / There are written emergency procedures for utility failures / Disaster plan
1.H.5.a.(5) / There are written emergency procedures for medical emergencies / Disaster plan
1.H.5.b / There are written emergency procedures that satisfy the requirements of applicable authorities and practices appropriate for the locale / Disaster plan
1.H.5.c.(1) / There are written emergency procedures that address when evacuation is appropriate / Disaster plan
1.H.5.c.(2) / There are written emergency procedures that address complete evaluation from the facility / Disaster plan
1.H.5.c.(3) / There are written emergency procedures that address when sheltering in place is appropriate / Disaster plan
1.H.5.c.(4) / There are written emergency procedures that address the safety of the evacuees / Disaster plan
1.H.5.c.(5) / There are written emergency procedures that address accounting of all persons involved in an evacuation / Disaster plan
1.H.5.c.(9) / There are written emergency procedures that address emergency phone numbers / Disaster plan
1.H.5.c.(10) / There are written emergency procedures that address notification of the appropriate emergency authorities / Disaster plan
1.H.6.a / The organization has evacuation routes that are accessible / Disaster plan
1.H.6.b / The organization has evacuation routes that are understandable to persons served, personnel, and other stakeholders, including visitors / Disaster plan
1.H.7.a / Unannounced tests of all emergency procedures are conducted at least annually on each shift and at each location / Staff training, Promoting Health & Safety, Disaster Plan
1.H.7.b / Unannounced tests of all emergency procedures include complete actual or simulated physical evacuation drills / Staff training, Promoting Health & Safety, Disaster Plan
1.H.7.c / Unannounced tests of all emergency procedures are analyzed for performance that includes areas needing improvement, actions to be taken, results of performance improvement plans, and necessary education and training of personnel / Promoting Health & Safety, Performance Improvement Plan, Disaster plan
1.H.7.d / Unannounced tests of all emergency procedures are evidenced in writing, including the analysis / Staff Traning, Promoting Health & Safety, Disaster Plan
1.H.8.a / There is immediate access to first aid expertise / Promoting Health & Safety, Disaster Plan
1.H.8.b / There is immediate access to first aid equipment and supplies / Promoting Health & Safety, Disaster Plan
1.H.8.c.(1) / There is immediate access to relevant emergency information on the persons served / Promoting Health & Safety, Client Record Quality, Disaster Plan
1.H.8.c.(2) / There is immediate access to relevant emergency information on the personnel / Promoting Health & Safety, Personnel Records, Disaster plan
Risk Management – Disaster Plan