Provider Name:
Provider Type:
License #:
Physical Address:
Main Telephone Number:
Emergency Telephone Number:
Fax Telephone Number (if available):
This form must be included with your provider's submission for approval of your comprehensive emergency management planto the county emergency management agency. Use it as a cross reference to your plan, by listing the page number and paragraph where the criteria are located in your plan to the left of each item. This will ensure accurate review of your provider's plan by the county emergency management agency. The items listed are the minimum requirements for your plan. If your provider is certified, you must also incorporate Centers for Medicare & Medicaid Services (CMS)’s requirements into your plan. All policies and procedures must abide by privacy and security related laws and regulations, including the Social Security Act which incorporates the Health Insurance Portability and Accountability Act (HIPAA).
1)Introduction
a)Provide basic information concerning the provider to include:
i)Name of Administrator/CEO, address, work telephone number, mobile telephone number, and email address. Include a home telephone number if available.
ii)Administrator/CEO’s designated alternate, telephone numbers, and email address.
iii)Name of designated Safety Liaison, email address, work telephone number, mobile telephone number, and 24-hour contact number. Include ahome telephone, pager number, and fax number if available.
iv)Nameof person who developed this plan, position title, address, email address, work telephone number, and mobile telephone number. Include a home telephone number if available.
v)Nameof person implementing the provisions of this plan, position title, address, email address, work telephone number, and mobile telephone number. Include a home telephone number if available.
vi)Type of ownership as designated on your licensure application, owner name, address, email address, work telephone number, and mobile telephone number. Include a home telephone number if available.
vii)Organizational chart withtwo identifying telephone numberscorresponding to the key management positions.
b)Introductory Material
i)Signatures
ii)Record of approvals
iii)Record of changes
iv)Record of distribution
v)Table of contents
c)Provide an introduction to the plan which describes its purpose,time ofimplementation, and the desired outcomethat willbe achieved through the planningprocess. Also provide anyotherinformation concerningtheprovider that has bearingon the implementation of this plan.
2)Authorities and References
a)Identify the legal basis for plan development and implementation to include statutes, rules and local ordinances, etc.
b)Identify reference materials used in the development of the plan.
3)Hazard Analysis
a)Outline and describe the potential hazards that the provider is vulnerable to such as hurricanes, tornados, flooding, fires, hazardous materials, transportation accidents, proximity to a nuclear power plant, power outages during severe cold or hot weather, gas leaks, etc. Indicate past history and lessons learned.
b)Identify site specific information concerning the provider to include:
i)Licensed capacity.
ii)Maximum number of staff on site.
iii)Identify types of clients served:
(1)Clients with cognitive or mental impairments
(2)Clients requiring special equipment or other special services, such as insulin, oxygen or dialysis
(3)Clients who are non-ambulatory
(4)Clients who require assistance
(5)Clients who do not require assistance
(6)Other - list types
iv)Identify hurricane evacuation zone as specified by the county in which the provider is located.
v)Identify which flood zone as identified on a Flood Insurance Rate Map or a Digital Flood Insurance Rate Map as distributed by Federal Emergency Management Agency (FEMA).
vi)Indicate proximity to a railroad or major transportation artery (to identify possible hazardous materials incidents).
vii)Identify if provider is located within a 10-mile or 50-mile emergency planning zone of a nuclear power plant and the evacuation zone if applicable.
4)Concept of Operations
This section ofthe plan defines the policies, procedures, responsibilities and actions that will be takenbefore, during,andafter anyemergencysituation.
a)Direction and Control
Define the management function for emergency operations. Direction and control provide a basis for decision making and identify who has the authority to make decisions for the provider.
i)Describe the procedures for ensuring timely activation of the emergency management plan and staffing during an emergency. This would include a listing of the potential hazards that the provider is vulnerable to such as hurricanes, tornados, flooding, fires, hazardous materials, transportation accidents, proximity to a nuclear power plant, power outages during severe weather, etc. The provider should have a pre-determined time of activation such as wind speed, flood water level, proximity of wildfire, etc. as well as a plan when no warning is given.
ii)State the operational and support roles for all established positions within the provider. This will be accomplished through the development of Standard Operating Procedures, which must be attached to this plan.
iii)Describe the procedures to ensure the following needs are supplied:
(1)Emergency power and, if applicable, natural gas or diesel. If natural gas, identify alternate means should loss of power occur (which would affect the natural gas system). What is the capacity of the fuel tank for the emergency power system?
(2)Transportation (may be covered in the evacuation section)
(3)Food and water
(4)Oxygen, if required for clients
iv)Describe the management of clients who will continue to receive services prior to, during, and immediately following an emergency.
b)Notification
Procedures must be in place for the provider to receive timely information on impending threats and the alerting of the provider’s decision makers, staff and clients of potential emergency conditions.
i)Describe how the provider will receive warnings of emergency situations.
ii)The procedures on how the provider’s staff in charge of emergency plan implementation will receive warnings of emergency situations, including off hours, weekends and holidays.
iii)Identify the provider’s 24-hour contact number, if different than the number listed in the introduction.
iv)Describe how staff and contractors will be alerted.
v)Describe how clients will be alerted and the precautionary measures that will be taken, including voluntary cessation of operations, how the provider shall demonstrate a good faith effort to comply with their emergency management plan,continuing to provide services to those that are in areas not likely to be evacuating, and confirm plans of those that will be relocating with family members and friends.
vi)Describe the procedures and policy for reporting to work for key staff, when the provider remains operational.
vii)Describe the procedures for alternative means of notification of key staff (may include mobile phones, satellite phones, contact with a community based ham radio group, public announcements through radio or television stations, face-to-face contact and, in medical emergency situations, contact with police or emergency rescue services) and communicating with the local county health department and county emergency management should the primary system fail.
viii)Describe the procedures for notifying those providers (for which mutual aid agreements are in place) to which clients will be evacuated.
ix)Describe the procedures for notifying clients and their responsible party that the provider is being evacuated or closed.
x)Describe the procedures for maintaining a current prioritized list of clients who need continued services during an emergency. The list shall indicate how services shall be continued in the event of an emergency or disaster for each client and if the client is to be transported to a special needs shelter, and shall indicate if the client is receiving skilled nursing services or has life-supporting or life-sustaining equipment and the client’s specific medication, equipment, and supply needs. The list shall be furnished to county health departments and to local emergency management agencies, upon request.
xi)Describe the procedures for notifying authorities of any on-duty staff or clients that they are unable to contact.
xii)Describe the procedures for notifying clients and their responsible partyif the provider is ceasing operations and clientservices has been delegated to another provider.
c)During an Emergency
i)When there is not a mandatory evacuation, some clients may decide to stay in place. Describe the procedures the provider will take to assure that all clients needing services will receive it, either from this provider or through arrangements made by this provider, the client or the client’s caregiver; and how this provider will contact other providers to arrange for services to the client.
ii)Describe the means by which the provider will continue to provide the same type and quantity of services to its clients who evacuate to special needs shelters, which were being provided to those clients prior to evacuation.
iii)When there is a mandatory evacuation, some clients may decide to stay in their home. Please describe the procedures to notify clientsand their responsible party that there may be a temporary disruption of services and when services can be expected to be restored.
iv)Establish and identify links to the local emergency operations center to determine a mechanism by which to approach specific areas within a disaster area.
d)Evacuation
Describe the policies, roles, responsibilities and procedures for the evacuation of clients.
i)Identify the staff position responsible for determining if and when evacuation is required.
ii)Identify the staff position responsible for implementing discharge or transfer and evacuation procedures including notifying all clients or caregivers.
iii)Specify at what point the mutual aid agreements and the notification of alternate providers will begin.
iv)Identify all arrangements made through mutual aid agreements, contracts,and memorandums of agreement or understandings that will be used to evacuate clients (copies of the agreements must be updated annually and attached in the appendix). Identify the transportation types being used. If transportation is coordinated through a centralagency, i.e., county emergency operations center (EOC), please explain. In addition, if there is a "transportation shortfall" in the area, please explain how the problem is addressed under current limitations.
v)Describe transportation arrangements for logistical support to ensure essential records, medications, treatments, and medical equipment remain with the client at all times. If this is arranged through a centralized agency, i.e., county EOC, please explain.
vi)Identify the pre-determined locations to which clients will be evacuated. If relocation is coordinated through a centralized agency, i.e., county EOC, please explain.
vii)Specify the amount of time it will take to successfully evacuate all clients to the receiving provider. Keep in mind that in hurricane evacuations, all movement should be completed before the arrival of tropical storm winds (45 mph sustained).
viii)Describe the procedures for staff accompanying evacuating clients.
ix)Describe the procedures for evacuating clients not being accompanied by staff. If staff is not accompanying, what measures will be used to ensure their safe arrival (i.e., who will render services during transport).
x)Describe the procedures for ensuring all clients are accounted for and are evacuated. Identify procedures that will be used to track clients once they have been evacuated (to include a log system). If clients will be considered discharged at the time of relocation, please explain.
xi)Describe the procedures for responding to family inquiries about clients who have been evacuated.
xii)Describe the resources necessary to continue essential services or referrals to other organizations subject to written agreement including how the provider will continue to provide services to clients who relocate in the same geographic service area or relocate outside the geographic service area.
e)After the Emergency and/or upon Re-entry to Affected Area:
i)Identify who is the responsible person(s) for authorizing re-entry to occur.
ii)Identify procedures for inspection of the provider to ensure it is structurally sound.
iii)Describe the procedures for contacting the emergency operation center after the disaster to report on damage, if any, and availability to continue services to their clients.
iv)Identify procedures for re-establishing contact with and services to clients, as prioritized, after their return to their residence.
v)Identify procedures for re-establishing contact with staff and contractors in order to resume services.
vi)Define how you will determine prioritization of services should the emergency result in fewer provider personnel or contractors being available immediately following the disaster.
5)Information, Training, and Exercises
This section shall identify the procedures for increasing staff, contractor, and client awareness of possible emergency situations and provide training on their emergency roles before, during, and after a disaster.
a)Describe the procedures that facilitate the efforts of the staff or contractor to establish, and keep updated, medication, supplies and equipment lists (as defined by to be kept in the client’s residence in case evacuation is ordered. Educating the client and caregiver about the need for this list and other items to accompany the client during the evacuation.
b)Describe how this provider will assist local emergency management agencies with special needs registration (Note: Clients must be registered with the special needs registry prior to an emergency, not when an emergency is approaching or occurring.).
i)Inform special needs clients about registration and provide information.
ii)Collect registration information from special needs clients for the special needs registry, in accordance with the established procedures of the local emergency management agency.
iii)Describe who will provide the information to the client and caregiver, e.g. family members, friends, etc., regarding the guidelines provided at there is a mandatory evacuation underway due to an emergency.
c)Identify how and when staff will be trained in their emergency roles and responsibilities during non- emergency times.
d)Identify an annual training schedule for all staff and identify the provider of the training. Training will include a definition of what constitutes an emergency, when the comprehensive emergency management plan will go into effect, the roles and responsibilities of essential and non-essential staff, the procedures for educating clients about the comprehensive emergency management plan, maintaining their medication, supplies and equipment and a comprehensive list of these, the special needs registry, special needs shelters, the clients’ plan for an emergency, and whom to contact if an emergency occurs with phone numbers and alternates. The training will also include information for staff on how they can work, if they choose to do so, with the local state or county agency who will be managing and staffing the special needs shelter during an emergency (pursuant to s. 456.38, F.S., and s. 381.0303, F.S.).
e)Identify the provisions for training new staff and contractors regarding their disaster related role(s).
f)Identify a schedule for exercising all or portions of the disaster plan on a semi-annual basis.
g)Describe the procedures for correcting deficiencies noted during training exercises.
h)Describe the method by which family members of clients will be made aware of theprovider’s emergency plan prior to a disaster.
6)Appendices
The appendices that follow are provided in support of the CEMP:
a)Appendix A – Agreements and Understandings
List and insert copies of annually updated mutual agreements, memoranda of understanding, or any other understandings entered into between the provider and any local, state, and county entities, or health care entities, and service providers that have responsibility during a disaster. This is to include reciprocal host provider agreements, transportation agreements, current vendor agreements or any other agreement needed to ensure the operational integrity of this plan.
b)Appendix B - Maps
i)Location Map, street-level including all service areas as needed.
ii)Evacuation Routes, primary and secondary evacuation routes with descriptions of how to travel to receiving providers for drivers.
c)Appendix C - Roster
Roster of staff and companies with key disaster related roles.
i)Organization chart listing the names, addresses, telephone numbers, and email addresses of all staff.
ii)Succession Plan defining chain of command to ensure continuous leadership and authority.
iii)Delegations of Authority as needed.
iv)List the name of the company, agency, organization, contact person, telephone number and address of emergency service providers such as transportation, emergency power, fuel, water, police, fire, rescue, Red Cross, emergency management, etc.
d)Appendix D – Information for Clients
Insert copy of information provided to educate clients about the procedures that may be necessary for safety during disasters. The information listed on be included for clients on the special needs registry in preparation for a possible evacuation to a special needs shelter.
e)Appendix E – Support Materials
Any additional material needed to support the information provided in the plan including a copy of the provider’s Standard Operating Procedures (SOPs).
f)Appendix F – Ambulatory Surgical Centers Only
i)Year center was built, type of construction, and date of any subsequent construction.
ii)Number of recovery beds, number of operating suites, maximum number of clients on site, average number of clients on site.
iii)Describe the ambulatory surgical center's role in the community wide comprehensive emergency management plan and/or its role in providing for the treatment of mass casualties during an emergency.
iv)Copy of the center’s current, approved fire safety plan and current fire inspection.
g)Appendix G – Adult Day Care Centers Only
Year center was built, type of construction, and date of any subsequent construction.
h)Appendix H – Home Medical Equipment Providers Only
Geographic Service Area:
All counties in Florida are served by this provider.
Only the following counties are served (list counties):