Snf Nf Form – Fill Out and Use This PDF

ATTACHMENT A

SNF/NF

Disaster Preparedness Plan Tool

FACILITY NAME: _______________________________

DATE OF REVIEW______________

All SNF, NF and SNF/NF are required by Federal regulations to “have detailed written plans and procedures to meet all potential emergencies and disasters, such as fire, severe weather, and missing residents” [ CFR 483.75 (m) F Tag 517 ]. California’s Health and Safety Code (H&S) and California’s Code of Regulations - Title 22, (T22) specify the “details” that are required in the facility emergency plan. To help you prepare for the external disaster plan review during the annual survey process, CDPH has prepared the following optional self assessment tool for your use. For comments or questions regarding this tool, please contact Kathy Clark, Disaster Preparedness Coordinator, Licensing & Certification at Kathy.Clark@cdph.ca.gov.

1)YES____ NO____ The plan was developed and revised with the advice and assistance of local emergency authorities? T 22 §72551(a)

2)When was the plan last reviewed? T 22 §72551 (c ________________________

3)How is staff trained to the plan? CFR 42§ 483.75 (m), T 22 §72551 (c)

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4)YES ____NO___ Disaster drills are held at six-month intervals. T22 §72551(e)

5)YES____NO ___ There is a written report of the facility’s participation. T §22 72551 (e) Date of last two disaster drills__________________ and

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6)How does the plan address: T22 §72551 (b) (1)

Sources of emergency utilities (power, gas, water):________________________

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Sources of emergency food:__________________________________________

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Sources of essential medical supportive materials:

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What does your plan identify as “essential medical supportive materials”? (i.e. meds, O2, battery packs for equip?)__________________________________________________________

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How does the plan make provisions for the distribution of water in the event of a loss of normal supply? CFR §483.70(h) (1)

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What provisions have been made to ensure infection control practices are maintained in the absence of adequate water supplies?

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7)What is the plan’s provision for recalling off-duty staff? T 22 §72551(b) (2)

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8)What are the lines of authority and staff assignments in the event of an emergency? T 22 §72551(b) (2) (3)

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9)How does the plan describe the moving of patients from damaged areas of the facility to undamaged areas? T 22 §72551 (b) (6)_________________________

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10)How does the plan address the conversion of useable space for the immediate care of emergency admissions? T 22 §72551(b) (4)

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11)What transportation will be provided for residents who need to be transferred in an emergency? T 22 §72551 (b) 6)

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12)YES____ NO_____ Does the plan contain evacuation routes, emergency phone numbers of physicians, fire, police, local emergency services, state agencies and relatives who need to be notified during an emergency? H&S code 1336.3, T 22 § 72551 (b) (9)

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13)What procedures are in place for maintaining a record of resident relocation? T 22 § 72551 (b) (8)

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14)What procedure is in place to assure that all pertinent personal and medical information shall accompany each resident who is moved, transferred, discharged or evacuated? T22 § 72551 (b) (10)

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15)What arrangements have been made for emergency housing where indicated? What agreements are in place with other facilities to provide temporary care for residents in an emergency? H&S Code 1336.3 (b), T22 § 72551 (b) (6)

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16)How does the plan address security of the facility during a disaster? T22 § 72551(b)(11)

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17)YES___ NO ___ Does the plan contain procedures for the emergency discharge of residents who could be discharge without jeopardy into the community? T22 §72551(b) (7)

18)YES ____ NO ____ Does the plan provide for the prompt medical assessment and treatment of residents who may have suffered adverse health consequences or require emergency care related to the disaster? H&S Code 1336.3(a) (3), T22 § 72551 (a) (12)

19)YES _____ NO _____ Does the plan include the assignment of a public relations liaison to release information to the public? T22 § 72551 (b) (13)

Additional Comments_________________________________________________

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CDPH/Licensing and Certification 10/07

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