Audit

EM 01.01.01. EOP Planning

A 1. The organization's leaders,including the administrator,medical director,the nursing leader and other leaders,participate in planning activities prior to developing an EOP.

Note- other leaders who participate in planning activities should include,but are not limited to,building services,food services,and housekeeping.

A 2. (D) The organization conducts a hazard vulnerability analysis ( HVA) to identify potential emergencies they could affect demand for the organizations services or it's ability to provide those services,the likelihood of potential emergencies occurring,and the consequences of those events. The findings of this analysis are documented! ( see also EM 03.01.01EP 1 ; IC 01.06.01, EP 4)

A 3. (D) the organization prioritizes the potential emergency emergencies identified in its hazard vulnerability (HVA) and documents these priorities.

A 4. The organization communicates its needs and vulnerability to community emergency response agencies and identifies the communities capability to meet its needs. This communication and identification occur at the time of the organizations annual review of its EOP and whenever needs or vulnerability change. ( see also EM 03.01.01 , EP 1)

A 5. The organization uses its HVA as a basis for defining mitigation activities ( that is, activities designed to reduce the risk of potential damage from an emergency).

A 6. The organization uses its HVA as a basis for defining the preparedness activities that will organize and mobilize essential resources. ( see also IM 01.01.03 EP 1-4)

A 7. The organization's incident command structure is integrated into its community command structure.

Note-the incident command structure should be scalable for different types of response to different emergencies.

A 8. (D) the organization keeps a documented inventory of resources and assets it has on site that may be needed during an emergency,including,but not limited to,PPE,water,fuel,food, and medical supplies and medication related resources and assets.( see also EM 02.02.03 EP6)

EM 02.01.01. The EOP organization

A 1. The organization leaders participate in the development of the EOP.

A 2. (D) the organization develops and maintains a written EOP that describes the response procedures to follow when emergencies occur ( see also EM 03.01.03, EP 5)

NOTE- the response procedures address the prioritized emergencies but can also be adapted to other emergencies that the organization may experience. Response procedures could include the following;
1. Maintaining or expanding services
2. Conserving resources
3. Curtailing services
4. Supplementing resources from outside the local community
5. Closing the organization to new residents
6. Staging evacuations
7. Total evacuation

A 3. The EOP identifies the organizations capabilities and establishes response procedures for when the organization cannot be supported by the local community in the organizations efforts to provide communication,resources and assets,security,safety,staff,utilities' or resident care for at least 96 hours.

NOTE- in the past years recommendations had advised organization's to prepare for emergencies of 72 hours. However,recent emergencies have often required a response period of much longer durations. As a result,organizations are now ADVISED to prepare for emergencies lasting 96 hours before the local community can help support the organization. This EP does not require organizations to stockpile supplies or continue operating for 96 hours. However,during emergencies of long duration,the organization needs to monitor its capabilities and adjust its response procedures to support an informed and proactive decision regarding how long the organization can deliver care safely. However this element does not require organizations to stockpile supplies or continue operating for 96 hours. However during emergencies of long duration,the organization needs to monitor-its capabilities and adjusts response procedures to support an informed and proactive decision regarding how long the organization can deliver care.

A 4. (D) The organization develops and maintains a written EOP that describes the recovery strategies and actions designed to help restore the systems that are critical to providing care,treatment,and services after an emergency.

A 5. The EOP describes the process for initiating and terminating the organizations response and recovery phases of the emergency including under what circumstance these phases are activated.

A 6. The EOP identifies the individual (s) who has the authority to activate the response and recovery phases of the emergency response.

A 7. The EOP identifies alternative sites for care,treatment,and services that meet the needs of the organization's residents during emergencies.

A 8. If the organization experiences an actual emergency,the organization implements its response procedures related to care,treatment,and services for its residents <3>

EM . 02,02.01. Communication

The EOP describes the following:

A 1. How staff will be notified when an emergency response procedures have bee initiated.

A 2. How the organization will communicate information and instructions to its staff and licensed independent practitioners during an emergency.

A 3. How the organization will notify external authorities that emergency response measures has been initiated.

A 4. How the organization will communicate with external authorities during an ongoing emergency.

A 5. How the organization will communicate with its residents and there families including how it will notify families when residents are relocated to alternate care sites.

A6. How the organization will communicate with The community or media during an emergency.

A 7. How the organization will communicate with suppliers of essential services ( such as transportation) equipment, and supplies during an emergency.

A 8. How the organization will communicate with other healthcare organizations in its geographic area regarding the essential elements of their respective command structures,including the names and roles of individuals in their command structure and their command centers telephone numbers
Note; The essential elements of a command center refer to operational functions managed from a command center such as medical care,security and hazardous materials.

A 9. How the organization will communicate with other healthcare organizations in their area regarding the essential elements of their respective command centers for emergency response.

A 10. How the organization will communicate with other healthcare organizations in its area regarding its resources and assets that could be shared in an emergency response.

A 11. How and under what circumstance the organization will communicate the names of residents and the deceased with other healthcare organizations in its area that are involved in the residents care,treatment,or service

A 12. How and under what circumstance the organization will communicate information about residents to third parties ( such as other healthcare,state health dept.,police,and FBI)

A 13. How the organization will communicate with identified alternate care centers.

A 14. The organization establishes back up systems and technologies for the communication activities identified in EM 02.02.01 EP 1-13

A 17. The organization implements the components of its EOP that require advance preparation to support communications during an emergency.
Note; some components of the EOP are not implemented unless an emergency is imminent. Other componets,however can and should be implemented in advance so that the organization is as prepared as possible.

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.