LTC Facility Survey Guidance and Provider Attestation Tool
Instructions to Surveyors: (Please remove this cover page before giving the attestation to the administrator.) At the Entrance Conference, give the LTC Emergency Preparedness Provider Attestation tool to the Administrator and ask him/her to complete the document and sign the attestation. Instruct the provider to return the document to the Team Coordinator before the end of the survey.
During the survey, observe or otherwise obtain evidence to verify the provider’s compliance with the following elements of an Emergency Preparedness plan:
Observe evidence of:
Plan was developed with assistance of local and state fire and safety experts1
Disaster Feeding plan is written3
Plans posted as required:
All Hazard Emergency plan posted at nurses’/attendants’ station(s) and other conspicuous locations1
Disaster Feeding plan posted in kitchen3
Food supplies as required (1 week staples, 48 hours perishables)11
Plan to ensure water is available to essential areas when loss of water occurs12, including:
Source of emergency water12
Storage of emergency water (potable/non-potable)12
Method for estimating volume of water required12 (potable/non-potable)(generally 1 gal per person per day)27
Confirm through interview:
Staff knowledge of generator-powered systems24
Staff knowledge of emergency procedures for various situations24, 25
Attestation'>Cover Page: Instructions for Survey Team
ALL HAZARD EMERGENCY PLANNING
LTC Facility Provider Attestation Directions: Administrator, Please complete and sign this attestation. Check each item that applies and is included in this facility’s emergency plan. Return the completed signed form to the Survey Team Coordinator by the end of the second day of survey.
Attestation: The undersigned representative(s) of the provider hereby attest that, pursuant to the facility’s responsibility to ensure the continuation of essential services at the above-named facility, the provider has developed an All Hazard Emergency Plan that addresses, at a minimum, each of the essential elements described below.
Name and Title (Please print)
The Plan addresses the following elements:
123Plan is written,4,7
Plan developed with assistance of local & state fire and safety experts1
Building security (access, crowd control, traffic control, etc)
Processes & persons to be notified8 (staff, external authorities)
Locations of alarm signals8
Plan includes a written transfer agreement with one or more hospitals
The Emergency/All Hazards Plan is posted at nurses’/attendants’ stations and other conspicuous locations.1,8
The Disaster Feeding Plan is posted in the kitchen.
456The plan addresses1,procedures for mitigation, preparedness, response and recovery strategies, for each of the following hazards, at a minimum:
Fire in the facility
Fire in the community
Power outage in the facility
Power outage – regional
Epidemic in facility
Epidemic/pandemic in community
Hazard Vulnerability Analysis (HVA): Facility conducted an HVA to identify emergencies which are potential threats to this specific facility and has developed relevant plans.
Sheltering-in-Place and Evacuation:
7Procedure for sheltering residents-in-place
8Evacuation procedures address relocating residents and staff: 7,
within the building
outside the community
outside the facility but within the community
Evacuation procedures address:
Transportation (residents, staff, equipment)
Transferring necessities between sites (food, meds, medical records)
New employees trained in emergency procedures when begin work in facility
Emergency procedures periodically reviewed with existing staff24
Unannounced, simulated drills using emergency procedures conducted at least twice a year, on all shifts, to test Plan’s effectiveness24,
26At least once a year, employees are instructed by head of local fire department in their duties in case of fire, and training is noted in facility’s records
Staff are familiar with the Disaster Feeding Plan3
Facility has provided training to assist staff in developing a personal (family) emergency preparedness plan.
1 105 CMR 150.015(E)(1) [R400]: Every facility shall have a written plan and procedures to be followed in case of fire, or other emergency, developed with the assistance of local and state fire and safety experts, and posted at all nurses' and attendants' stations and in conspicuous locations throughout the facility.
2 §483.75(n)] [F519]: ... the facility... must have in effect a written transfer agreement with one or more hospitals...
3 105 CMR 150.009(F)(9)[R265]: All facilities shall plan and post a Disaster Feeding Plan and staff shall be familiar with it. This plan shall include alternate methods and procedures to be used when equipment is not operable, including proper sanitation of dishes and utensils.
4 §483.75(m)(1) [F517]: The facility must have detailed written plans and procedures to meet all potential emergencies and disasters, such as fire, severe weather, and missing residents.
5 Mitigation: “Those activities an organization undertakes in attempting to lessen the severity and impact of a potential emergency”. From: JCAHO 2006 Long Term Care Accreditation Standards for Emergency Management Planning.
6 Preparedness: Those activities an organization undertakes to build capacity and identify resources that may be used if an emergency occurs. From: JCAHO 2006 Long Term Care Accreditation Standards for Emergency Management Planning.
7 NFPA 101 18/126.96.36.199 [K48]: There is a written plan for the protection of all patients and for their evacuation in the event of an emergency. (188.8.131.52)
8 105 CMR 150.015(E)(2)] [R401]: The plan shall specify persons to be notified, locations of alarm signals and fire extinguishers, evacuation routes, procedures for evacuating helpless patients, and assignment of specific tasks and responsibilities to the personnel of each shift.
9 150.015(E)(3) [R402]: All personnel shall be trained to perform assigned task.
10 §483.35(h)(2) [F371]: The facility must store, prepare, distribute, and serve food under sanitary conditions.
11 105 CMR 150.009(F)(5) [R263]: An adequate supply of food of good quality shall be kept on the premises at all times to meet patients’ or residents’ needs. This shall mean supplies of staple foods for a minimum of one-week period and of perishable foods for a minimum of 48 hours.
12 §483.70(h)(1) [F466]: Regulation: The facility must establish procedures to ensure that water is available to essential areas when there is a loss of normal water supply. Guidelines: The facility should have a written protocol which defines the source of water provisions for storing the water, both potable and non-potable, a method for distributing water, and a method for estimating the volume of water required.
13 105 CMR 150.015(D)(11)(e)] [R399]: Oxygen tanks shall be safely stored and labeled when empty.
14 §483.60(a) [F426]: A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.
15 105 CMR 150.015(G)(4)(d) [R414]: Adequate supply of clean, ironed or drip dry bed linen, bed rubbers, blankets, bedspreads, washcloths, and towels of good quality and in good condition. This shall mean a supply of linen equal to at least three times the usual occupancy. In facilities that provide Level I or II care, towels and washcloths shall be changed and laundered every day; in facilities that provide Level III and IV care, at least every week and more frequently, if indicated. Bed linen shall be laundered at least weekly and more frequently, if needed.
16 §483.70 [F454]: The facility must be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel and the public.
17 §483.35(h)(3) [F372]: The facility must dispose of garbage and refuse properly.
18 §483.65(c) [F445]: Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.
19 105 CMR 150.016(C)(3) [R430]: Wastes and garbage shall be stored and disposed of at proper intervals in a manner to prevent fire hazard, contamination, transmission of disease, a nuisance, a breeding place for flies and insects, or feeding place for rodents.
20 §483.65(b)(3) [F444]: The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice.
21 NFPA 110, 6.3.1: The EPSS shall be maintained to ensure….the system is capable of supplying service within the time specified for the type and…duration specified for the class.
22 105 CMR 150.017(B)(16)(f) An automatic transfer switch shall be installed to transfer to emergency power within ten seconds.
23 §483.70(b)(2) [F455]: 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.... Procedures: Check that the emergency generator starts and transfers power under load conditions with 10 seconds after interruption of normal power.... When life support systems are used, the facility must provide emergency electrical power with an emergency generator (as defined in NFPA 99, Health Care Facilities) that is located on the premises.
24 §483.75(m)(2) [F518]: The facility 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.
25 150.015(E)(4) [R403]: Simulated drills testing the effectiveness of the plan shall be conducted for all shifts at least twice a year.
26 105 CMR 150.015(D)(3)] [R389]: At least once a year, employees of the home shall be instructed by the head of the local fire department or his representative on their duties in case of fire and this noted in the facility's record.
27 42 CFR 483.25(j) hydration (i.e., F327) and interpretative guidelines: “…A general guideline for determining baseline daily fluids needs is to multiply the resident’s body weight in Kg times 30cc (2.2lbs-1kg), except for residents with renal or cardiac distress…” Also see, New England Diet Manual for Extended Care Facilities, Massachusetts Dietetic Association, 2003 pages. 12, 92.