Comprehensive Emergency Management Plan.pdf

COMPREHENSIVE

EMERGENCY

MANAGEMENT

PLAN (CEMP)

Center Memorandum 00-19-08

FOR OFFICIAL USE ONLY

Center Director’s Office Emergency Management

CEMP

VA CARIBBEAN HEALTHCARE SYSTEM CENTER MEMORANDUM NO. 00-19-08

SAN JUAN, PUERTO RICO APRIL 2019

Page

TABLE OF CONTENTS

Comprehensive Emergency Management Plan

Emergency Operations Plans (EOP):

Attachment A - Hazard Vulnerability Analysis

Attachment B - Activation & Communication

Attachment C - Hospital Incident Command System (HICS)

Attachment D - Primary Response Functions

Attachment E - Support Response Groups

Attachment F - Disaster Privileges

Attachment G - VA \ DoD NDMS Contingency Plan

Attachment H - Evacuation Plan

Attachment I - Bomb Threat

Attachment J - Fire Emergency Response

Attachment K - Radiation Incidents

Attachment L - Chemical & Biological Incidents

Attachment M - Earthquake

Attachment N - Hurricane

Attachment O - Continuity of Operations Plan (COOP)

Attachment P - Tsunami

Attachment Q - Mass Casualty Incident

Attachment R - Mass Fatality Management

Attachment S - Shelter in Place

Attachment T - Surge Capacity

Attachment U - Management of Pandemic Influenza, Biological Pathogens & Outbreaks………703

Attachment V – Management of Highly Contagious Disease………………………………………..724

Attachment W –Information Systems Failure………………………………………………………….773

Attachment X – Behavioral Health Response Plan …………………………..……………….……..777

Attachment Y – Mass Prophylaxis Plan…….….…………………….………………………………..784

Attachment Z – Disaster Emergency Medical Personnel System (DEMPS) …

Attachment AA– Response to a Catastrophic Incident…..……………………

Attachment AB– Fuel Management Plan

Attachment AC– Dealing with Suspisious Mail and Packages

COMPREHENSIVE EMERGENCY MANAGEMENT PLAN (CEMP)

I. PURPOSE: The purpose of the Comprehensive Emergency Management Plan (CEMP) is to provide a programmatic framework to reduce all hazards at all levels of VA Caribbean Healthcare System (VACHS) in accordance with the VHA Directive 0320, Comprehensive Emergency Management Program (CEMP). The plan includes processes that are designed to evaluate risks that may adversely affect the life or health of patients, staff, and visitors. The emergency management plans describing the process for disaster readiness and emergency management activities occurring across four phases: mitigation, preparedness, response and recovery, and implements it when appropriate.

A. Mission: The VACHS mission is to honor America’s veterans by providing exceptional health care that improves their health and well-being. In order to accomplish our mission all VACHS staff must have the committed to providing a safe, secure, and therapeutic environment at its main facility and clinic for all patients, staff and visitors. The emergency management program is designed to support patient safety and effective care by providing reliable information that allows facility management and staff to make better emergency management decisions and to evaluate key issues and opportunities for improvement of emergency management performance. Consistent with this mission, the VACHS has established and provides ongoing support for the Comprehensive Emergency Management (CEM) described in this plan.

B. Scope: The facility has an Environment of Care Committee (EOCC) consisting of a cross representation of the facility’s staff in accordance with the Center Memorandum No.

001FM-14-55, Environment of Care Committee. The EOCC monitors training and competence of staff and assesses conditions of the physical plant, grounds, and equipment through building inspections, environmental rounds, safety inspections, and various performance improvement initiatives. Through review of reliable information, management is able to make the best decisions regarding safety concerns and to evaluate emergency management performance related to key issues with opportunities for improvement. The EOCC monitors and evaluates all emergency management reports in a quarterly basis. Since 2009 an Emergency Management (EM) became a separate chapter of the Joint Commission Standard and gave more autonomy to Emergency Management Committee (EMC) to takes action and makes recommendations to the facility executive leadership, including the Director, the Deputy Director, Chief of Staff, the Associate Director and the Associate Director for Patient Care Services who serves as the Governing Body (Executive Team) on issues related to EM. The VACHS EMC may issue assignments to committee members and non-committee staff for follow-up actions, improvements and completion of reports (see CM 00- 15-98: Emergency Management Committee).

II. POLICY:

A. VA Caribbean Healthcare System (VACHS) executive leaders, including leaders of the medical staff, participate in planning activities prior to developing an Emergency Operations Plan.

B. The procedures explain in the CEMP apply to all VACHS staff and facilities that include: VA Medical Center, Outpatient Clinics, Home Base Primary Care (HBPC), Long Term Care (LTC) Program, Behavioral Health, Research, Radiology and Clinical Laboratory. Each Service Chief has the responsibility to write and implement their own Emergency Preparedness Plan that will expand on the details of his/her service response to an emergency or disaster.

C. VACHS EMC conducts a hazard vulnerability analysis (HVA) to identify potential emergencies that could affect demand for the hospital’s services or its ability to provide those services, the likelihood of those events occurring, and the consequences of those events.

The findings of this analysis are documented in the Attachment A.

D. Effective planning reduces the impact of emergencies on the quality of patient care and increases the facility’s ability to continue to provide necessary patient services.

E. Many types of emergencies can be identified from past organizational or community experiences. Evaluating the past experiences provides a baseline of likely threats in future emergencies. Planning should include responses to these likely future emergencies.

F. Planning considers facilities, space, personnel, supplies, communications, and other resources needed to provide essential services under less than ideal conditions.

G. Planning considers on-duty and off-duty staff and other resources when determining what staff is needed to maintain essential services.

H. Planning considers conditions that may require modifications of normal patient care routines including treatment. The conditions may require discontinuation of services, patient transfer, facility evacuation, or discharge of patients.

I. Periodic drills are essential for maintaining staff awareness of emergency procedures and for evaluating the effectiveness of plans.

J. Scheduled drills and actual implementations of the emergency management program are observed, documented, and critiqued to identify opportunities for improvement.

Actions taken to address deficiencies are documented and tested during subsequent drills.

All drills are conducted in accordance with multiple organizations standards including but not limited to the Joint Commission (TJC), Commission on Accreditation of Rehabilitation Facilities (CARF), National Fire Protection Association (NFPA), Veterans Healthcare Administration (VHA) Emergency Management Capabilities Assessment Program (EMCAP) and others. Summaries of the emergency management program activities are presented to EMC for review and recommendations.

1. Comply with accepted standards for emergency management.

2. Provide a safe, secure, and therapeutic environment for patients, staff and visitors.

3. Integrate emergency management practices into daily operations.

4. Identify opportunities to improve performance.

K. VACHS plan for managing six critical areas of emergency response in order to assess our needs and prepare staff to respond to events most likely to occur regardless of the cause(s) of an emergency situation. The six critical areas of emergency management are as follows:

1. Communication. VACHS developed a plan to maintain communication pathways both within the Healthcare System, Clinics and to critical community resources.

(see Attachment B, Activations and Communications, Attachment W, Information Systems

Failure Plan).

2. Resources and assets. VA Caribbean Healthcare System Logistics Section identified materials and supplies, vendor and community services, as well as state and federal programs, as essential resources that Hospital Incident Command Staff must know to access in times of crisis to ensure patient safety and sustain care, treatment, and services. (see Attachment C – HICS & Job Actions Sheets, Logistics). VACHS Logistics Section and Facility Management Services keeps a documented inventory of resources and assets it has on site that may be needed during an emergency, including but not limited to, personal protective equipment, water, fuel and medical, surgical, and medication-related resources and assets.

(CM-90-16-02 Delivery/Pick up of Emergency Supplies, CM-119-16-28 All Hazard Emergency Cache, CM-120-14-04 Meals Furnished by Nutrition and Food Service without Charge in an Emergency Situation).

3. Safety and Security. The safety and security of patients are the prime responsibility of the VACHS during an emergency. As emergency situations develop and parameters of operability shift, all VACHS employees must provide a safe and secure environment for their patients and staff. (see the Center Memorandum, 07B-13-10 Security Management Plan and CM-00-16-81, Safety Management Plan, CM-118-16-15 Hospital Wide Safe Patient/Resident Handling and Movement Policy).

4. Staff responsibilities. During an emergency, the probability that staff responsibilities will change is high. As new risks develop along with changing conditions, staff will need to adapt their roles to meet new demands on their ability to care for patients. If staff cannot anticipate how they may be called to perform during an emergency, the likelihood is that VACHS will not sustain itself during an emergency increases. (see Attachment C – HICS & Job Actions Sheets, Attachment D

5. Primary Response Groups, Attachment E – Service Responsibilities, Int. &

Ext. Emergencies, VHA Handbook 5010 Employee Accountability System).

6. Utilities management. A VA Caribbean Healthcare System (VACHS) depends on the uninterrupted function of its utilities during an emergency. The supply of key utilities, such as power, potable water, ventilation, and fuel, must not be disrupted or adverse events may occur as a result. (see Center Memorandum (CM) 001FM-14-27, Contingency Plans for Unexpected Losses of Utilities, and CM 118-14-25, Nursing Contingency Plans for Unexpected Loss of Utilities).

7. Patient clinical and support activities. The clinical needs of patients during an emergency are of prime importance. VACHS have clear, reasonable plans to address the needs of patients during extreme conditions when the Healthcare System infrastructure and resources are taxed. VA Caribbean Healthcare System has a sound understanding of our response to these six critical areas of emergency management. We have developed an “all hazards” approach that supports a level of preparedness sufficient to address a range of emergencies, regardless of the cause. VACHS also identified potential hazards, threats, and adverse events, and assess their impact on the care, treatment, and services they must sustain during an emergency. This assessment is known as a Hazard Vulnerability Analysis (HVA) and is designed to assist healthcare organizations in gaining a realistic understanding of their vulnerabilities, and to help focus their resources and planning efforts. Finally, VACHS use the information from their assessments to develop Emergency Operations Plans, which should be tested regularly, and use the lessons learned to improve. Mental health professionals, social workers, and chaplains will also be required to help in their respective expertise during the emergency and disaster response by giving support for both patients and staff. Plans should be done by respective chiefs.

VACHS Emergency Operations Plans (EOP) describes the response procedures to follow when an emergency occurs. The response procedures address the prioritized emergencies but can also be adapted to other emergencies that the VACHS may experience.

EOP identifies the hospital’s capabilities and establishes response procedures for when the VACHS cannot be supported by local community in the hospital’s efforts to provide communications, resources and assets, safety and security, staff, utilities, or patient care for at least 96 hours of operations.

III. RESPONSIBILITIES:

A. The Associate Director receives regular reports on activities of the Comprehensive Emergency Management Plan (CEMP) from the EMC. The Associate Director reviews reports and, as appropriate, communicates emergency management related concerns about identified issues and regulatory compliance to the Center Director.

B. The Center Director reviews reports and, as necessary, communicates concerns about key issues and regulatory compliance to appropriate departments, services, and staff.

The VACHS Executive Team collaborates with appropriate departments, services, and staff to establish operating and capital budgets for the emergency management program.

C. The Chief of Staff, the Deputy Director, Associate Director, the Associate Director for Patient Care Services, and Services Chiefs have the responsibility to establish policies, procedures, and practices for granting emergency privileges to clinical staff and authorization for non-clinical staff to work in the facility during an emergency operations implementation.

D. The EMC Chairperson or Associate Director and the Emergency Program Manager (EPM) with the collaboration of the Area Emergency Manager (AEM) have the responsibility for identification, collection, and analysis of information regarding emergency management deficiencies, development of plans for improvement, and emergency response. Training of staff and volunteers is facilitated by the Associate Chief of Staff (ACOS) for Education and Nursing Education.

E. The EOCC coordinates processes within the Environment of Care Standards.

Membership on the EOCC is by appointment from the Director and includes representatives from administration, clinical services, and support services. The EOCC meets monthly to receive reports and to conduct reviews of emergency management issues quarterly.

Additional meetings may be scheduled at the request of the EOCC Chairperson.

F. The Director is the individual who has the authority to activate the response and recovery phases of the emergency response. The Director also authorizes key staff to take immediate and appropriate action in the event of an emergency. An emergency is a situation that poses an immediate threat to life or health or threatens damage to equipment or buildings. Each Service Chief, program and site managers are responsible for orienting new staff members to the department, program, site, and job specific emergency management procedures.

G. The Director reviews reports and, as appropriate, communicates safety related concerns about identified issues and regulatory compliance. The Clinic Director also authorizes key staff to take immediate and appropriate action in the event of an emergency.

H. Individual staff members are responsible for learning, following job and task specific procedures for safe operations delegated by their supervisors. Individual staff members are also responsible for learning and using reporting procedures. All staff is responsible to support the VACHS Medical Center and Clinics during the activation and response of the emergency management plans.

IV. PROCEDURES:

A. Management of Emergency Planning

1. Identification of Specific Procedures: The hospital staff conducts a hazard vulnerability analysis to identify potential emergencies that could affect the need for its services or its ability to provide those services. The Hazard Vulnerability Analysis (HVA) is a systematic approach to assessing the probability, severity and consequence of hazards or threats/events that may affect the continued operation of the VACHS and surrounding community. The input to the HVA is performed by the facility Emergency Program Manager

(EPM), the Area Emergency Manager (AEM), the Operating Unit Managers and the Community Emergency Management Agencies. Some threats to individual Operating Units are so severe that they may interrupt the continuity of critical operations in the VACHS and Clinics. The Emergency Management Committee (EMC) oversees the annual HVA process to ensure that all major threats to the VAMC and Clinics are accounted for and assessed. Using the input submitted by Operating Unit Managers, the EMC must create a prioritized list of hazards, threats and events that require incident-specific guidance annually.

Finally, the HVA is approved by the Director. Based on the HVA, specific procedures are developed to respond to a variety of disasters.

a. The four phases of emergency management dealt with in these procedures are:

(1) Mitigation

(2) Preparedness

(3) Response

(4) Recovery

The VACHS use its HVA as a basis for defining mitigation activities. VHA Emergency

Management Performance Improvement Funds and/or VACHS Operational Funds are used to improve and resolve mitigation activities. Specifics are found in the Comprehensive Emergency Management Plan Attachments and in department, program, and site-specific procedures. Emergency Operation Plan explain the response procedures could include the following: Maintaining or expanding services, conserving resources, curtailing services, supplementing resources from outside the local community, closing the hospital to new patients, staged evacuation, total evacuation.

2. Community Planning: The AEM establishes priorities, in coordination with federal, state, and local emergency management programs, as identified in the hazard vulnerability analysis for which mitigation, preparation, response, and recovery activities will need to be undertaken. Also, the VACHS and Outpatient Clinics establishes with the community: priorities among the potential emergencies identified in the hazard vulnerability analysis, the hospital's role in relation to a community wide emergency management program and an "all-hazards" Hospital Incident Command System (HICS) within the hospital that links with the community’s command structure. The Incident Command System (ICS), a component of the National Incident Management System (NIMS), provides a universal structure and process to manage the organization’s response and recovery activities.

The EMC defines and, where appropriate, integrates the facility’s role and relationship with federal, state, and local emergency response agencies, including identification of the relevant command structures.

3. Management Emergency Planning: The EPM and AEM are responsible for the development and maintenance of a written Comprehensive Emergency Management (CEM) plan with policies and procedures describing the processes for disaster readiness and emergency management. The EPM and AEM are responsible for the emergency plans implementation.

The EPM and AEM are responsible to include the organization’s leaders including the medical staff in the development of the emergency management plans.

The Director or the Administrative Officer of the Day (AOD) is responsible for specific processes to initiate the response and recovery phases of the emergency operations plans.

The facility Hospital Incident Command System (HICS) staff in conjunction with VISN 8 Network Emergency Management Coordination Center (NEMCC) will provide for continuing of operations plans (COOP) support and/or the re-establishment of operations following an emergency and/or disaster.

The Emergency Management Committee (EMC) is established to coordinate and oversee the Comprehensive Emergency Management Program (CEMP). The EMC should meet at a minimum on a quarterly basis.

EMC Membership - The membership of the EMC should be specified in the CEMP and should include: (see CM 00-18-98: Emergency Management Committee).

a. Associate Director (Chairperson)

b. Emergency Manager (EM)

c. Area Emergency Manager (AEM)

d. AFGE union representative (Ad-Hoc)

e. Chief, Emergency Medicine Unit

f. Chief, Fiscal Service

g. Chief, Facilities Management Service

h. Chief, Human Resources

i. Chief, Logistic Service

j. Chief, Police Service

k. Safety Manager

l. Chief, Patients & Community Relations

m. Chief, Surgical Service (Ad-Hoc)

n. Chief, Medical Service

o. Chief, Infectious Disease

p. Coordinator Infectious Control

q. Chief, Nuclear Medicine Service (Ad-Hoc)

r. Chief, Information Technology Operations Services

s. Chief, ACOS Primary Care

t. Chief, Healthcare Administration Services

u. Chief, Health Information Management Section

v. CARF Safety Representatives (Ad-Hoc):

(1) Physical Medicine and Rehabilitation Services (PM+R)

(2) Compensated Work Therapy (CWT)

(3) Blind Rehab Service (BRS)

(4) Spinal Cord Injured Department (SCID)

The EMC should report to, or have a very close liaison with, the Environment of Care Committee.

Roles and functions of the EMC can be found at Center Memorandum 00-18-98.

4. Staff Notification: The plan provides processes for initiating the response and recovery phases of the plan, including a description of how, when, and by who the phases are to be activated. The Incident Commander (IC) is responsible for the processes of notifying staff when response measures are initiated. Each Service Chief is responsible for assuring their staff notification lists are current and will notify their staff of an emergency when directed by incident command.

The attachment Activation and Communications (Attachment B) covers the list of phones numbers available in case of an internal and external emergency.

Also covers the resources available to create a mass notification message to our staff.

5. Notification of External Authorities: Any employee or staff member of the Healthcare System who receives notification or observes an incident that could result in a disaster shall report this information immediately to the Police Communications Center at extension #11444. The Police Communication Center will immediately contact the Director and inform of the emergency. The Police Communication Center will also notify external local authorities (e.g. Police, Fire Dept, etc), if necessary.

The attachment Activation and Communications (Attachment B) covers the list of phones numbers available in case of an internal and external emergency.

The EPM and AEM uses the incident command structure that utilizes designated staff to notify local, state, and federal agencies when an emergency has occurred that is serious enough to warrant their involvement or notification. This would include the exposure to a Weapons of Mass Destruction and any other terrorism attack.

6. Staff Assignments: The Incident Commander uses the HICS structure to assign roles to essential staff personnel and provides physical identification as necessary.

The EOP HICS (Attachment C) list processes for identifying and assigning staff to cover all essential staff functions under emergency conditions.

7. Support, Care, Space, Supplies, and Security: The hospital incident command system (HICS) staff will direct department/service, program, and site managers to modify or discontinue services, to control patient information and manage patient transportation.

The HICS Infrastruture Branch Director is responsible for managing the space that may be needed during an emergency and provide the staff direction on managing the space needed during the emergency.

The HICS Operations Section Chief has the authority to assign and deploy employees to alternative roles and responsibilities during an emergency, as necessary. The Incident Management Team (IMT) will be responsible for providing support for employees, staff family support activities, transportation, and stress debriefing.

Patient Family Support Branch Director will provide information of external agencies that can provide staff family support during and after a disaster (example:

shelters, transportation and other critical services).

The HICS Logistics Section Chief with the assistance of department, program, and site managers will manage critical supplies needed to meet the needs of patients, visitors, and staff.

The Security Branch, in consultation with Operations Chief will control the security for the facility and all sites affected by the emergency or disaster. The Security Branch will notify and request assistance from external law enforcement/security agencies as necessary. Lockdown Procedures are directed under the Security CM-07B-13-10 and CM- 07B-14-16.

The VACHS All Hazard Pharmacy Cache is established to provide a stockpile of medication and material supplies that would be required to support patient care in the event of a significant incident related to All Hazard event. The cache has been designated to maintain the infrastructure of the facility and ensure supplies are available to treat patients, staff and individuals seeking treatment during an All Hazard event.

8. News Media: Interaction with the news media will be handled exclusively by and at the direction of the Director and Public Information Officer.

The Attachment B Activation and Communications covers the list of phones numbers available in case of an internal and external emergency. Also covers the resources available to create a mass notification message to our patients, staff and family.

9. Evacuation: The Attachment J Fire and the Attachment H Evacuation describes the procedures for evacuating the entire facility (both horizontally and, when applicable, vertically) when the environment cannot support adequate care, treatment, and services. At the direction of the HICS Incident Commander, the evacuation will be implemented when a facility or site cannot sustain or support patient care and treatment.

10. Alternate Care Sites: The facility has identified alternative care sites within Puerto Rico (i.e. NDMS Hospitals) and other appropriate care sites throughout the VISN 8 that have the capabilities to meet the needs of patients and staff, when the environment cannot support adequate care, treatment, and services. Outpatient Clinics at Ponce, Mayaguez can be use as Continuity of Operations (COOP) sites to maintain command and control of the primary administrative functions. Outpatient Clinics at Ponce and Mayaguez are the alternate location for the VACHS Business Continuity and Business Relocation. At the request of the IC and with the approval of the Director, patients, staff, and equipment will be relocated to specified facilities. These relocations will be carried out according to the procedures within the Attachment H - Evacuation, which include provision for medications;

interoperability communications between the hospital and the alternative care sites, medical records, supplies, patient tracking, and transportation.

11. Identification of Care Providers and other Staff: Lists of identified care providers and other available staff are provided to the incident command structure. Physical identification is provided as necessary. If external resources are necessary Human Resources Management Service has specific process for granting emergency privileges to dependent healthcare providers from the community (see Attachment F Disaster Privilieges).

The Credentialing and Privileging Office has specific process for granting emergency privileges to independent healthcare providers from the community (Medicine Bylaws).

12. Cooperative Planning and Communication: The Attachment G -

VA/DoD/Federal/Local Contingency defines the NDMS cooperative planning with other healthcare organizations in the contiguous geographic area to facilitate the timely sharing of information about:

a. Essential elements of their command structures and control centers for emergency response.

b. Names, roles, and telephone numbers of individuals in their command structures.

c. Alternate means of communications.

d. Resources, services, and assets, including staff that could potentially be shared or pooled in an emergency response.

e. Names of patients and deceased individuals brought to their organizations to facilitate identification and location of victims of the emergency. VACHS will communicate the names of patients and the deceased with other health care organizations in accordance with Privacy Policy CM 00-13-15.

13. Communications: The Attachment B - Activation and Communications identify backup internal and external communication systems that will sustain emergency communications in addition to advance preparation to support communications during emergencies.

14. Alternative Staff Roles: The Hospital Incident Command System (HICS) is consistent with the National Incident Command System (NIMS) doctrine used in the local community. The HICS provides the authority to assign staff to alternative roles and responsibilities during an emergency, as necessary.

15. Alternative Utilities: The CEMP and the Facility Management Services (FMS) Contingency Plan (see Center Memorandum 001FM-14-27, Contingency Plans for Unexpected Losses of Utilities) identifies an alternative means of meeting essential building utility needs when the hospital is designated by its emergency management plan to provide continuous service during an emergency (for example, electricity, water, ventilation, fuel sources, medical gas/vacuum systems).

HICS Infrastructure Brach Director and Logistics Section Chief, keeps a documented inventory of resources and assets it has on site that may be needed during an emergency, including, but not limited to, personal protective equipment, water, fuel, and medical, surgical, and medication-related resources and assets.

16. Isolation/Decontamination: The emergency operations procedures on the Attachment K - Radiological and Attachment L – Biological & Chemical Terrorism, explain the emergency management response to an internal or external event that requires isolation or decontamination procedures. The VACHS offers First Receivers Decontamination Training to critical personnel for isolation and/or decontamination of victims on an incident with biological agents, radioactive materials or chemicals to comply with VHA Directie 0320.06.

17. Patient Hygiene and Sanitation: The emergency operations procedures for patient hygiene and sanitation will be follow in accordance with Facility Management Service Environmental Program Activities CM 001FM-14-13, Nursing Contingency Plans for Unexpected Loss of Utilities CM 118-14-25.

B. Emergency Management – Elements of Performance:

1. Provide Education and Training to Staff on Emergency Operations. All employees must receive education and training consistent with their roles and responsibilities in emergencies. Staff members, licensed independent practitioners, students and volunteers, as appropriate, can describe or demonstrate the following:

a. Risks within the hospital’s environment.

b. Actions to eliminate minimize or report risks.

c. Procedures to follow in the event of an incident.

d. Reporting processes for common problems, failures and user errors.

2. Testing of Response Plans

a. The EPM and AEM are responsible to implement and test the response phase of the emergency operations plans (EOP). The implementation tests the elements of the plan twice a year in response to an actual emergency or in planned drills.

b. The EPM and AEM are responsible to implement and test the response phase of the emergency management plan once a year if the facility is a Business Occupancy as defined by the Life Safety Code and is not a community designated disaster receiving station.

c. The EPM and AEM are responsible for assuring drills are conducted at least four months apart and no more than eight months apart.

d. The EPM and AEM are responsible for planning one drill that involves an influx of volunteer or simulated individuals served.

e. Only San Juan VA Medical Center offers emergency services and is a community-designated disaster receiving stations and will conduct at least one drill a year that includes an influx of volunteers or simulated patients.

f. The EPM and AEM are responsible for planning and participating in a least one community-wide practice drill annually relevant to priority emergencies identified in its hazard vulnerability analysis. The drill must assess communication, coordination, and the effectiveness of the organization and community’s command structure.

g. The EPM and AEM are responsible for all drills to be critiqued to identify deficiencies and opportunities for improvement.

h. Tabletops exercises, though useful in planning or training, are acceptable substitutes only for community wide disaster drills.

V. RECOVERY PHASE

A. All Chiefs of Services will, within three working hours after "All Clear" has been received, submit a report to the Medical Center Director including the following:

B. Damage caused in their areas of jurisdiction.

C. Man-hours worked overtime by their subordinates.

D. A critique of the functioning of the Emergency Operations Plan, with recommendations for improvement, if any. Within one week after the critique, the Mitigation Team will discuss any projects or special actions that can be taken in order to prevent damage to areas, or to improve the capability of response in future events.

E. Activate Behaivoral Mental Health Plan may be necessary.

A. REFERENCES:

A. VHA Directive 0320-01, Comprehensive Emergency Management Program(CEMP), 2017

B. VHA Emergency Management Program Guidebook, 2015 C. Center Memorandum No. 001FM-11-55, Environment of Care Committee D. Comprehensive Accreditation Manual for Hospitals: The Official Handbook 2016, Joint Commission on Accreditation of Healthcare Organizations.

E. Centers for Medicare Medicaid Services Emergency Preparedness Final Rule, F. NFPA 1600: Standard for Disaster/Emergency Management Programs and

Business Continuity/Continuity of Operations Programs, 2016.

G. Health Care at the Crossroads, Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems, 2003 by the Joint Commission on Accreditation of Healthcare Organizations.

H. Standing Together, an Emergency Planning Guide for America's Communities, 2005 by the Joint Commission on Accreditation of Healthcare Organizations.

I. Surge Hospitals: Providing Safe Care in Emergencies, 2006 by the Joint Commission on Accreditation of Healthcare Organizations.

J. Presidential Directive 5 (HSPD-5), National Incident Management System (NIMS).

NIMS, National Response Framework (NRF) created by Homeland Security

K. Homeland Security Presidential Directive 21 (HSPD-21), National Strategy for Public Health and Medical Preparedness.

L. National Continuity Policy, National Security Presidential Directive (NSPD 51)/Homeland Security Presidential Directive 20 (HSPD-20)

M. FEMA- National Response Framework, May 2013 N. VISN 8 Emergency Operations Plan, 11-16-2011

VI. RESCISSION: Center Memorandum No. 00-16-08 Comprehensive Emergency Management Plan (CEMP), dated March 2016.

VII. EXPIRATION DATE: April 2022

VIII. FOLLOW-UP AND RESPONSIBILITIES: Emergency Program Manager will conduct an annual review after the annual Hazard Vulnerability Analysis.

Original Signed Document

CARLOS R. ESCOBAR, BED-ARCH, MSHP, FACHE

Director

Attachments A through CC

ATTACHMENT A

A T T A C H M E N T A

HAZARD VULNERABILITY ASSESSMENT (HVA)

HAZARD VULNERABILITY ASSESSMENT

I. PURPOSE:

The Hazard Vulnerability Analysis (HVA) is a way to focus attention on those hazards that are most likely to have an impact on the VISN Office and the surrounding community. The list of hazards includes possible events or threats that may occur within the community or VA property. Events that impact the community many times are brought into the facility. It is VA Caribbean Healthcare System (VACHS) intended that a HVA be seen as an evolving document and be reviewed at least annually within the Joint Commission Environment of Care Emergency Management annual report.

II. TYPE OF EVENTS

A. Natural Threats

1. Hurricane & Flooding: The VA Caribbean Healthcare System (San Juan VA Medical Center) is located in the Caribbean Sea to the South and the Atlantic Ocean to the North. Being a small island in the tropics the largest natural threat is Hurricanes. However, there is more damage in Puerto Rico due to flooding which occurs in different parts of the island almost every year. The Medical Center itself is not prone to flooding, but some of its employees live in areas where flooding is endemic.

2. Earthquake: Puerto Rico is located in an earthquake zone. Western

Puerto Rico is more seismically active than the rest of the island. One of our outpatient clinics is located in the more active zone, Mayaguez. However, the last significant earthquake occurred in October of 1918. There is, therefore, a moderate risk for earthquake and a tsunami, if it is originated near Atlantic Ocean or the Caribbean Sea.

B. Technological Threats

i. Fire: The multiple buildings at VA Caribbean Healthcare System Center faces routine medical facility fire hazards. There have been few fires of significance in the close to 40-year history of the hospital. The concrete construction of the medical center as well as the outlying clinics make them fairly safe in a fire but the threat of fire in isolated areas is always present. The VACHS Medical Center and clinics has various Fire Department Stations located within a 10-mile radius.

ii. Water Outage: The infrastructure on the island although as advanced as any in this part of the world, suffers more from over-population than due to a lack of technical knowledge or resources. Droughts on the island in 1994 and 1995 induced water rationing for many months. Water rationing also was implemented in 1974 when the population was less than at present. The station has a water storage capability of 2,000,000 gallons.

iii. Electrical Utility: Electrical power outages are relatively frequent.

However, the station has installed considerable electrical power generation to run the entire hospital including the air conditioning. This VACHS and clinics have more emergency power generation than any other hospital on the island. The Air Conditioning System is dependent on water so a disaster affecting both water availability and electrical power would affect our patients.

iv. Communications: Information system failure have become many frequent in the past years in the VACHS mainly due to infrastructure problems between PR and US.

C. Events Involving Hazardous Materials

i. Hazmat/Fixed Facility: The VA Medical Center stores and uses many hazardous materials, most associated directly with the provision of medical care. The outpatient clinics have far less dangerous materials due to their limited medical operation.

ii. Radiological Incident/Fixed Facility: There are no Nuclear Power Plants in Puerto Rico. However, there are major pharmaceuticals located throughout the island that produce radioactive medical supplies. The VACHS Medical Center stores and uses significant quantities of radiological material; therefore, the hazard is considered high.

However, the station has a Radiation Officer and there are various contractors that are specialized to deal with hazardous materials.

D. Human Related Events

i. Civil Disorder/Terrorism: As a visible US Government facility, the risk of demonstrations always exists. There have been bomb threats in the past, which have been taken seriously and remain a high-risk factor in Puerto Rico. Active political events always signify a risk due to the existence of political factions who have been known to commit violent acts. The FBI does not think Weapons of Mass Destruction will be used by the locally known terrorist groups however it is always a possibility given the sometimes-volatile political situation in Puerto Rico and even in the US Virgin Islands.

ii. Also Labor General Strikes in 1998 with the Puerto Rico Telephone Company and in October 2009 with Multiple Organizations, demonstrate a significant impact to the economic and operational status of local government and healthcare system. This is considered a high-risk element.

iii. An Active Threat Response Plan is now required for all our VA Healthcare Facilities as preparedness actions against recent workplace violence events. An Active Shooter is an individual actively engaged in killing or attempting to kill people in a confined and populated area; in most cases, active shooters use firearms(s) and there is no pattern or method to their selection of victims. Active shooter situations are unpredictable and evolve quickly. Typically, the immediate deployment of law enforcement is required to stop the shooting and mitigate harm to victims.

III. REFERENCES AND FURTHER ASSISTANCE.

A. Puerto Rico Seismic Network:

http://redsismica.uprm.edu/english/.

B. National Weather Service Weather Forecast Office San Juan, PR http://www.srh.noaa.gov/sju/

C. VHA Emergency Management Guidebook:

http://vaww.ceosh.med.va.gov/01hp/pages/guidebooks.shtml

D. The Joint Commission Emergency Management Resources:

https://www.jointcommission.org/emergency_management.aspx

B. Centers for Medicare Medicaid Services Emergency Preparedness Final Rule http://files.constantcontact.com/d901e299001/51f80a78-4ff1-4585-8270-f2aea6d39172.pdf http://redsismica.uprm.edu/english/ http://www.srh.noaa.gov/sju/ http://vaww.ceosh.med.va.gov/01hp/pages/guidebooks.shtml https://www.jointcommission.org/emergency_management.aspx http://files.constantcontact.com/d901e299001/51f80a78-4ff1-4585-8270-f2aea6d39172.pdf http://files.constantcontact.com/d901e299001/51f80a78-4ff1-4585-8270-f2aea6d39172.pdf

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Current HVA insert

ATTACHMENT B

E M E R G E N C Y O P E R A T I O N P L A N

A T T A C H M E N T B

A C T I V A T I O N A N D

C O M M U N I C A T I O N S

ACTIVATION AND COMMUNICATIONS

I. PURPOSE:

Describe the processes for initiating and terminating the VACHS response and recovery phases of an emergency. Explain the procedures of how staff will be notified that emergency response actions have been initiated.

A. Description of the Threat/Event:

Activation of the Emergency Operations Plan will depend on the identification of an internal or external emergency or disaster that may demand an emergency response from the VACHS Medical Center and Clinics leadership and employees. The emergency may originate within the hospital’s premises (Internal Disaster) or on the hospital’s community (External Disaster). An external disaster could also have internal implications (e.g.

Earthquake, Hurricane, etc.).

II. PROCEDURE:

A. Process for Activation of the Emergency Management Plan

The first person that becomes aware of an internal emergency or receives notification of an internal or/and an external emergency should immediately notify the Police Communications Center at extension #11444. The Police Communication Center will immediately contact the VACHS Medical Center Director (regular business hours) or the AOD (after regular business hours) and inform of the emergency. The VACHS Center Director or the AOD would become the Incident Commander (IC) (Attachment C) who has the authority to activate the response and recovery phases of the emergency operations plans response.

The Information Resources Management Services Chief will identify backup internal and external communication systems that will sustain emergency communications in addition to advance preparation to support communications during emergencies.

B. Response Procedures During Regular Business Hours:

Any employee or staff member of the VACHS Medical Center who receives notification or observes an incident that could result in a disaster shall report this information immediately to the Police Communications Center at extension #11444 (Clinics has different numbers).

The Police Communication Center will immediately contact the VACHS Medical Center Director and inform of the emergency. The Police Communication Center will also notify external local authorities (e.g. Police, Fire Dept., etc.), if necessary. The VACHS Center Director would become the Incident Commander (IC) and decide if activation of the Emergency Operations Plan is necessary (Attachment C).

During regular business hours, if the Center Director is not accessible, then the Acting Center Director or the person of higher hierarchy on the Medical Center’s Chain of Command (Attachment C) would become the Incident Commander.

If nobody of higher authority is immediately available, the employee that identified the emergency situation will become the interim Incident Commander and should review Attachment C of this plan for specific actions. The employee will remain in-charge until a supervisor or higher official reports to the scene or the Hospital Command Center (HCC).

Based on the apparent magnitude of the disaster, the IC will establish and direct a

HCC or alternative sites for command and control. Also, Outpatient Clinics at Ponce and Mayaguez are the alternate location for the VAMC Business Continuity and Business Relocation. The Incident Commander will designate individuals to assume the HICS positions for the Command Core Group and the four General Sections Chiefs for Operations, Finance, Planning and Logistics (Figure 1). Each of these individuals should read their respective Job Action Sheets (JAS) carefully and put on the HICS vest for identification (Attachment C). The JAS are available at the Office of Emergency Management, Office of the Center Director, Office of Chief of FMS, Office of the Associate Center Director, Office of Chief of Fiscal Service, and Office of the Associate Director for Patient Care Services and the Admissions Unit.

Once activated and organized, the HCC will gather the information necessary for a complete assessment of the damages (if any) to the Medical Center and the capabilities and resources available to initiate a response to the Internal or External Emergency or Disaster.

Based on which type of external disaster takes place, the Incident Commander will utilize the appropriate EOP (e.g. Hurricane, Earthquake, VA/DOD Contingency, etc.). The HCC will notify to the local, state and federal authorities the VACHS Medical Center’s capacity to receive victims.

C. External Facilities Support

VACHS may activate the Hospital Command Center (HCC) to provide support to external facilities in any emergency situation. VACHS HCC will coordinate assistance requested by the external facility experiencing an emergency beyond their ability to effectively respond.

The following criteria should be considered for HCC activation:

1. Any incident/event that requires facility EOP activation

2. Any emergency involving media coverage to a substantial event

3. Anticipated community assistance request from the facility

4. Damage or disruption severely affecting patients, infrastructure, and/or services to the facility

VACHS EOP outlines the policies and procedures that the medical center will follow in the event of an emergency. It provides standards that facilities should follow in their local planning efforts and reporting requirements during emergencies.

D. Recovery Procedures

To return to normal operations from an emergency, the VA Caribbean Healthcare

System will undertake the following:

1. When deemed appropriate, the Director/Incident Commander may call “All Clear” for the emergency situation, while the recovery efforts continue until the hospital is back to normal operations

2. The Incident Commander will notify the VA Caribbean Healthcare System

PAO/Emergency Manager to alert the staff of the end of the event by announcing an “All Clear” by normal announcement methods.

3. The staff may also be notified through alternate announcements including

Intranet messages, personal communication devices (pagers, walkie-talkies, or cellular telephones), and an overhead paging system.

4. Call cascade or mass electronic (“LiveProcess”) notification procedures can be initiated for all Staff concerning the need to report to their Service or to remain at their current locations.

5. The Incident Commander ensures community and VISN 8 Emergency

Management Services are notified of the “All Clear” action.

6. Upon announcement of the “All Clear”, for the disaster/emergency situation, while the recovery efforts continue until the hospital is back to normal operations; all information concerning the disaster/emergency will be recorded and properly filed for later reference.

7. Section Leaders and HICS staff will contact Service Chiefs to receive information and critiques concerning the response to the emergency.

8. All expenses and overtime information will be provided to the Finance Section for documentation. Evidence of the damage or abnormalities caused by the emergency, or response to the emergency, should be documented through photographs or descriptive writings.

9. All communication equipment, data processing systems, and other equipment used during the emergency will be evaluated for appropriate use in the next emergency and consumable supplies documented for restocking.

10. All HICS vests and emergency phones will be gathered and made ready for the next emergency.

11. The physical surroundings of the HCC shall be cleaned and furniture repositioned for normal operations. All documents used for event will be gathered and replacement copies of forms and documentation sheets will be replenished.

12. The HCC staff and appropriate designees will conduct the After-Action

Review (AAR); an evaluation of the emergency and the response within three business days of the event.

13. The Public Information Officer will communicate to local Media needed information concerning the “All Clear”.

Figure 1

Regular business hours Incident Command Core Group and Section Chiefs.

Each position is identified by the HICS’ title and the pre-designated Medical Center official. If the pre-designated official is not immediately available, the “acting” official will assume that role or the Incident Commander designates one.

E. Response Procedures…