Special: How prepared are US nursing homes for disasters?

This is an article I wrote with a colleague about disaster preparedness for nursing homes and long-term living facilities.


Introduction


How prepared for disaster are the nation’s nursing homes?  The last thing nursing home operators should be worried about is exposure to legal liability because of failure to comply with industry best practices in disaster compliance, but many more facilities are at risk than one would have thought. 


National Deficiencies in Preparedness


The recently released 2012 Health and Human Services Office of the Inspector General report indicates serious deficiencies in nursing home planning and preparedness nationwide.   

In 2006 the Department of Health and Human Services (DHHS) Office of the Inspector General (OIG) issued a report indicating that, while the majority of the nation’s nursing homes had written Emergency Operations Plans in place, many of the plans lacked provisions recommended by planning experts. 

In response, the Centers for Medicare & Medicaid Services (CMS) issued guidance checklists for emergency planning of health care facilities, long-term care (LTC) ombudsman programs, and State survey agencies (SA). 

Medicare and Medicaid have long required nursing homes to meet minimum standards, including having a written emergency plan, meeting minimum training thresholds, and developing contingency plans for facilities to qualify to receive federal funding for their patients.

The 2006 and 2012 reports found that the majority of nursing homes had written plans.  This is no surprise as there are commercially available off the shelf plans that allow a facility administrator to simply fill in the blanks.  So-called “checkbox” emergency plans are rarely successful, because the process of developing a plan is multi-tiered. 


Incomplete Disaster Programs


True contingency planning means working off a set of potential scenarios, identifying and mitigating hazards, assessing and developing alternative methods of addressing risks, and then writing a plan that makes as much intuitive sense to employees and residents as possible. 

The plan itself, however, is not the finish line.  An effective disaster program requires training and regular exercising for success. 

The Centers for Medicare and Medicaid Services (CMS) responded to the shortfall found in the 2006 report by creating a checklist of best practices for nursing homes and assisted care facilities to follow in developing their preparedness plans. 

The CMS checklist was not enshrined as federal law, but was to serve as guidance for how plans should be crafted and the range of issues to which they should respond.

The 2012 OIG report indicates that serious deficiencies remain in the area of disaster preparedness in nursing homes across the United States.  The largest shortfall was in the area of the CMS checklist itself – with many of the nursing homes only including about half of the relevant information from the CMS checklist.

Nursing homes had unreliable transportation contracts, almost no collaboration with local emergency management officials and little planning for residents who developed health problems during the emergency.  State and local agencies designed to support nursing homes had little contact with residents until after the disaster had passed and the contacts that did occur were usually centered on compliance-oriented concerns rather than on assisting in the provision of services. 


Designing an Effective Program



Any competent disaster manager will tell you that contingency planning and training are critical to effective disaster response.  Ultimately, the OIG has developed a set of recommendations to revise Federal law to set specific requirements for nursing home emergency operations plans and training and has encouraged the Administration on Aging to develop a set of model Policies and Procedures. 

Alone, this will not be enough.

There is no question that nursing home (or any business) needs specialized guidance on implementing an effective disaster and emergency planning.  For example, conducting a thorough hazard analysis (which is a precursor to the design of a disaster plan) would be an immeasurably difficult and frustrating process without the assistance of a trained and experienced emergency manager; much less developing a robust risk assessment and developing a plan to prepare for and respond to hazards. 

Experience and best practices have demonstrated time and again that these are the minimum critical elements of an effective disaster program:

• Identifying hazards specific to the facility;
   
• Assessing risks specific to the facility (these are not the same as the hazards);
  
• Developing a robust emergency/disaster plan that addresses how to mitigate, prepare, respond and recover from hazards and risks specific to the facility;
  
• Designing an employee-wide training program, with regular exercises to test the disaster program’s effectiveness;
  
• Implementing a system of regular updates to prevent it from going obsolete.

Ensuring Complaince

Furthermore, because this industry is heavily regulated, an attorney who specializes in this type of compliance should “vet” the plan entirely. Putting aside the potential loss of life, failing to adequately prepare your facility to the Best Practices of the industry (i.e., at a minimum following the CMS guidance checklist, adequately training staff, exercising the plan and adequately preparing for contingencies) opens the facility up to legal liability for any harm that results from ill-planning. 

Simply meeting Title 22 standards will not be enough to insulate the facility or its parent companies from legal liability for failure to comply with industry Best Practices.  Also, failure to meet new Title 22 standards, when they are drafted and signed into law, will expose the facility to K-tagging, administrative letters and potentially the loss of Federal and state funding sources for patients/clients.

In short, by failing to comply with industry best practices, operators of nursing homes and assisted care facilities not only put their residential clients at risk, but also put themselves and their livelihoods at risk.


What Can Be Done Immediately


While you should hire an experienced emergency manager to design and implement your disaster program and have it reviewed by an attorney for compliance, there are a few things a nursing home or long-term living facility can do immediately to increase their level of compliance and reduce the likelihood of your disaster program failing when disaster strikes:

• Call every one of the emergency contact numbers to ensure the numbers are correct;
  
• Examine your agreements for transporting and housing residents forced to evacuate your facility;
  
• Conduct a fire drill. While this does not compensate for a complete disaster exercise, at least you can get an idea of emergency response awareness;
  
• Schedule a training for your staff on the basic protocols of your plan;
  
• Clean the plan up. If you have purchased a template (which is not an acceptable long-term solution), ensure there aren’t any blank spaces.

These are by no means plenary; however, they may at least provide a jump start for your disaster program. Your facility is a critical disaster partner, taking care of some of the most vulnerable individuals in the community.

The national trend still points to facilities not remaining ready for disasters that may strike.  Don’t be one of them. The amount you spend on constructing an effective disaster management program that is compliant with all the applicable laws could in the long run save money, prevent property damage, and save lives.


Jude Egan is California based attorney with a practice area in Title 22 compliance for nursing homes.  Please contact him at: jude@judeeganlaw.com.

www.judeeganlaw.com


Patrick Hardy is a Certified Emergency Manager® and Advanced Level Emergency Manager® who works with nursing home and long-term living facilities.  Please contact him at: phardy@hytropy.com.


Patrick Hardy

phardy@hytropy.com

Twitter: @hytropy

Facebook: Hytropy

The 15 US National Planning Scenarios

After the September 11th, 2001 attacks on New York and the Pentagon, the US Federal Government began to get serious about organizing federal resources for a catastrophic, peacetime disaster.

However, the government quickly recognized that it could not prepare for all of them, so they decided to find 15 major disasters that encompass the general spectrum of catastrophic events. So the question became:  which ones should be included in the 15? There are literally thousands of disaster events, which cause serious disruption to the US infrastructure. 

They quickly came to an answer, and began to organize themselves accordingly. The entire history of this organizational zeitgeist is beyond the scope of this article; however, the basic chronology is that in 2002, Federal departments, state, tribal, territorial and local governments developed a series of scenarios known as the National Planning Scenarios as the 15 threats the government would prioritize in disaster planning, response, and recovery.

Each of these represents a highly destructive event, including terrorist attacks, natural disasters, and technological emergencies. Some are more likely to occur than others, with some having never been experienced, some having experienced periodically, and some regularly.

Thankfully, the full scope of these disasters very rarely occur (if at all), but the conception of their magnitude from past experiences should give us as business owners and citizens pause. Before I discuss these in any more detail, take a look at the list:

1. Improvised Nuclear Device
2. Aerosol Anthrax
3. Pandemic Influenza
4. Plague
5. Blister Agent
6. Toxic Industrial Chemicals
7. Nerve Agent
8. Chlorine Tank Explosion
9. Major Earthquake
10. Major Hurricane
11. Radiological Dispersal Device
12. Improvised Explosive Device
13. Food Contamination
14. Foreign Animal Disease
15. Cyber Attack

While you may think that most of these will “never happen”, The Homeland Security Council in tandem with the newly-minted Department of Homeland Security believed that there was enough of a threat of these that citizens and others living in the US should prepare for them.  You have probably heard of some of these, and can recount their histories. Others you may not have heard of, or don’t know the full scope of their impact.

That will change soon.


During the next 12 months, I will discuss each of these in some detail. In each discussion, I will elaborate on their history, on their impact, what you can expect in a response from the government, and some measures to protect your business and employees. I think as you read about them, you will discover a lot of interesting information that will help you prepare for a major catastrophic event, wherever you happen to live.

How you react to the information will vary, but I think universally what you will find is that the disaster response to these events isn’t always “obvious” or “common sense”. These disasters defy common sense. That is why when they strike so many people get injured or die. When I teach at the EMS school, I tell the paramedics and EMTs that a little education can save your life and those of your patients.

Next week, I will start with an Improvised Nuclear Device.

Be ready to Reverse Disaster.



Patrick Hardy

phardy@hytropy.com

Twitter: @hytropy

Facebook: Hytropy

5 Disasters That Can Strike Anywhere

A few weeks ago I was visiting a friend and her husband in their beautiful home on the Central Coast of California. During dinner at some inauspicious moment, she told her husband that I was a Disaster Manager. Interested, he smiled, and then told me, “We really don’t get disasters, so I don't think you would make much money here.”

What he didn’t realize (and I didn’t tell him, as I didn’t want to annoy the hosts who just served me the best crème brûlée I had ever had) was that they were actually in one of the highest danger zones in California. However, it wouldn’t have mattered if I had been enjoying that crème brûlée in Biloxi, Mississippi, Beijing, China, London, England or South Africa.  Every place in the industrialized world shares virtually the same 5 risks on top of the ones that are more endemic to their own region.

1. Flooding

Flooding is without question the most destructive disaster in the world. They can strike with or without warning, can linger for days or weeks, and create substantial after-effects. The unimaginable horrors of Hurricane Katrina were magnified by the flooding of the streets and byways of New Orleans. And it doesn’t require a massive hurricane to spark a flood. Tropical Storm Claudette in 1979 brought 45 inches of rain to Alvin, Texas and caused more than $1.8 billion (in 2012 dollars) in damage. Long after Hurricane Diane in 1955 subsided, the resulting floods in Pennsylvania killed 200 people and caused billions in damage.

Floods are recorded in every state in the US. This has become such a ubiquitous disaster that the US has now instituted the Flood Warning System for communities to participate in flood preparedness.  

 

2. Space Weather

This may sound like something out of a sci-fi novel, but the threat is very real in our age. Space weather can knock out satellites or interrupt communication links on the groud, which would grind your cell phone use to a halt.

We have now become so reliant on telecommunications infrastructure, that any interruption in those satellites that deliver it can be a major emergency. Electric grids and utilities can also be affected. In the early 1970’s a solar blast nearly caused near complete blackout in the US East Coast after the grid became overloaded. In an upcoming entry I am going to discuss solar flares and their effects on your business, but they are just one of numerous types of space weather. Meteors, space debris, and even electromagnetic pulses can cause massive disruptions on services that we now take for granted.

Ironically enough, it is the “less-civilized” societies that are impacted the least by these events. In fact, these are disasters that weren’t even catalogued as such (other than meteor strikes) until the mid to late 20^th Century.  However, any business disaster plan should keep at least one eye upward.

3. Fire

Fire has been nature’s equalizer since the dawn of time. The US Centers for Disease Control and Prevention in 2005 published statistics that stated that death from fire and burns were the 5^th leading cause of unintentional death in the United States. There is little need to elaborate on that statistic, but obviously, businesses can be the victim of a fire as easily as any residence. As you go through your office, you probably notice the fire alarm on the wall, the fire extinguisher, the smoke alarm above you, and perhaps the fire hose line behind glass that says “Fire Department Use Only”. These are testament to the seriousness communities take to the threat of fire.

However, an office does not have to be in a complete conflagration to be interrupted by a fire. Even a small trash fire that spills into a hallway can have a very serious effect on your business. Mandatory employee evacuation, injuries, smoke/fire damage, water damage from the fire departments suppression efforts, possible fines from the incident, and even possible criminal sanctions all make it a very difficult event.   

4. Earthquake

If you live and work on Planet Earth, earthquakes can strike. Our globalized age of commerce means that these threats can have massive effects near and far. The earthquake and resulting tsunami in Japan, for example, had a significant impact on the production of vehicles in the US and the EU because of the constriction of supply. Literally, cargo could not leave the harbors because the ships had been run aground or beached, or were destroyed in the aftermath.

I have had the opportunity to live in one of the most earthquake-prone areas of the world (Southern California), and one of the least prone (South Louisiana). And while each one has its own unique hazards, this was one that should be considered regardless of your business resides.  

5. Technological Emergencies

Technological emergencies refer to those that involve human-made “technologies” such as a power outage, hazardous materials spills, dam failures, mine collapses, etc. In a future entry, I will talk about some of the most spectacular (and obscure) examples of these events, and what were learned from them. Thankfully, the US, UK, European Union, and many industrialized nations take significant steps to prevent these types of events, but they still do occur.

Even if your business is in an area you think are not typically prone to these disasters, take a second look. The bridge you take to work in the morning, the tanker truck with the strange placards on the side, the factory you pass with the big smoke-release tower, the small dam that is used for electricity generation, that big dirt hole where they are building the new football stadium are all places that have the potential for massive destruction if the elements line up.

 

Conclusion

Regardless of where you enjoy your crème brûlée, there is no place that has a complete immunity from disaster. Floods, space weather, fires, earthquakes and technological disasters can occur anywhere. The solution is to identify them, prepare for them, and do what is necessary to Reverse Disaster.

Patrick Hardy

phardy@hytropy.com

Twitter: @hytropy

Facebook: Hytropy

5-Step Evaluation of your Disaster Manager

I speak routinely at conferences around the country on disaster planning and training, and one of the questions I inevitably get is, “How do I know who is qualified to do the disaster program?”

It is an excellent question; because there are a lot of people out there who claim they know how to write a disaster plan and administer a disaster program effectively. Frankly, most of those claims fall very short, either because they don’t have the training, the experience, the education or the professional maturity.

Here is a 5-step process to effectively evaluate that person’s credentials:

1. Experience

This one is easy.  Make sure the person you plan to hire has direct, on-point experience with businesses of your size and type. Now, if you run a lampshade and glazing factory, don’t expect to find very many planners with "lampshade and glazing" experience. However, find someone with solid experience in business continuity and emergency management (in other words, someone who knows how to plan for the immediate effects, and the long term recovery of business operations).  

The number of years they have is important, but what is more important is their direct experience. If you had heart trouble, would you rather have a general practitioner with 25 years of experience, or a cardiologist who has direct experience treating patients with your condition, but with only 10 years?

They must have experience in:

·   Constructing a disaster plan from scratch (not from templates);

·   Training diverse workforces on a disaster plan;

·   Running exercises, conducting after-action reviews, and implementing lessons-learned in a business setting;

·   Maintaining a program’s readiness, including monthly updates and conducting annual audits.

But, here are some other things to think about:

·  Hazardous Materials – If you have HAZMAT in your facility, make sure the planner has HAZMAT licenses and experience (those licenses are beyond the scope of this entry, but HAZWOPER and Certified Hazardous Materials Manager are minimums).  

·  Healthcare/Convalescent Facility – If you are a healthcare facility, your planner should have experience working with the Joint Commission, Medicare and other federal requirements, and specific state laws such as California’s Title 22. They should preferably be a licensed care provider as well, so they understand patient dynamics and transport realities (such as an EMT, Paramedic, or Stage Nurse).

·  Information Technology – This one is pretty obvious, especially if you have on-site databases or servers.  The planner should have IT experience, or have a technologist who works on IT continuity. If they don’t, you can’t expect them to understand the sophistication of a network dynamic.

Just as a final note:  I have nothing against firemen or other former emergency responders (I am one myself), but don’t be dazzled by “25 years as a Battalion Chief and Captain in the ABC City Fire Department” or “Assistant Chief of Police of Big City USA”. They may be good at what they do, but being in the fire department or law enforcement doesn’t necessarily mean you have the skills necessary to administer a complete program. Put them through the same rigorous process you would for anyone you are hiring as a consultant.

2. References

This one is so easy. Ask the planner what they did for every facility. You don’t have to call each one, just make sure they have worked on facilities like yours, and can handle your requirements.

3. Education

Education is an important part of the person’s overall qualifications, but don’t be overhyped about the “alphabet soup” education degrees. I was once competing for a consulting contract with a Ph.D. from a major university, and I remember the managers being very impressed when he recited his educational background. Then he said something I will never forget: “Writing an emergency plan is exactly the same as writing a doctoral dissertation.” I remember being completely incredulous, because those are NOT the same at all. In fact, the skill sets for each are so different they barely compare to one another.

Here are some things to look for:

·  Undergraduate Degree – They should have at least an undergraduate degree. The reason for that is simple: they need to have the versatility to write technical and non-technical papers in a clear, straight-forward manner. They don’t have to have a B.A. from Harvard, but they do need to have a sophisticated vocabulary, and have the research skills to interpret and synthesize the newest best practices from research.

·  Master’s Degree in Emergency Planning – Just because they have a master’s degree in Emergency Planning or “Homeland Security Studies”, doesn’t mean they know how to write your plan or administer your program. These programs focus on public policy, terrorism, or studying the effects of disasters on populations from a “global” perspective.  They may be familiar with government responses to disasters and lessons-learned, but might not understand the dynamic details of a complete disaster program.

4. Training

Since September 11, 2001, the US has placed additional emphasis on training, particularly on natural disasters and terrorism. Any professional you hire needs to have training that complements any combination of education and experience.

Some of the training to look for on a CV includes:

·  Incident Command System (ICS) – Ask them if they have taken ICS 100, 200, 300, 400, 700, 800. These are baseline trainings in how the government will organize itself in a disaster, and should be something you should require in your disaster planner. If they haven’t, don’t waste your time in hiring them.

·  1^st Responder Training and Red Cross Training;

·  Federal Anti-Terrorism Training offered by FEMA and DHS (particularly if you have a brick and mortar facility or are a highly visible facility);

·  Health and Safety Training

·  Insurance and Risk Management Training.

5. Certifications

While certification does not guarantee that the person is competent, it does mean that person has been qualified by other peers, and therefore more likely they have the experience, training, expertise, and professionalism to construct your disaster program. You can use certification as a short cut when scrutinizing candidates. The industry now has a variety of certifications with varying degrees of acceptance, but these two are the gold standard:

• Certified Business Continuity Professional (CBCP)/Master Business Continuity Professional (MBCP) – These are granted to business continuity professionals who have passed a rigorous test and have years of experience. Continuity professionals with these certifications are qualified as some of the best in the world.

•

•  Certified Emergency Manager (CEM) – This is the emergency management equivalent of the CBCP, and requires the passing of a difficult test, hundreds of hours of training, six major contributions (teaching, speaking, etc.) to the discipline, many years of experience, an essay, and disaster experience in a significant role. Needless to say, those with the CEM are considered highly skilled professionals.
  

Conclusion

Your disaster plan should be the best it can be. Therefore, don’t hire people who don’t have the qualifications, experience or training to write a plan. Don't just pawn it off to just anyone. Get a top professional; they will ensure that your program is optimally ready to Reverse Disaster. 

Patrick Hardy

phardy@hytropy.com

Twitter: @hytropy

Facebook: Hytropy

 

The 5 Safety Hazards in a Disaster Area

A Kentucky Building after a Tornado

The unbelievably active Tornado season we experienced in the US this year has resulted in destructive events that have leveled cities in multiple states. It isn’t until the storm is over that we realize how much devastation it has caused. I’ve been to a lot of these disasters, both as a working emergency manager and as a victim of one, and I am continually amazed by the power of Mother Nature.

In our contemporary dialogue on rebuilding, there is always a rush to “get things back to normal” as quickly as possible. However, what also needs to be considered in that process is safety. To be succinct, disasters areas are highly unsafe places, and extreme caution should be exercised during any cleanup activity.

These are just some of the hazards you should consider as you work or live in a rebuilding disaster zone:

1. Technological Hazards

Of the five I enumerate here, this one is perhaps the most visible. Technological hazards include anything that is man-made that is either damaged or compromised as a result of the disaster. A short list includes: power lines, broken glass, water mains, concrete broken off a building, etc. Just because the storm is over doesn’t mean these are not a continuing hazard.

Power lines, for example, are a major source of concern for several reasons: first, live lines don’t have to have “sparks”, and may not look like the stereotype depicted in movies; second, electricity can be easily conducted through water; third, even if the power is out, that doesn’t mean current isn’t flowing through the lines.

To stay safe:

·  Stay away from down power lines;

·  Watch for chemicals or other hazardous substances;

·  Wear closed toe shoes; (ideally boots)

·  Use common sense;

2. Animals

This is a hazard that I think isn’t taken as seriously by some, because, as a civilization we humans feel a special kinship with animals. My ten-year-old cat (Buster) is sleeping soundly as I type away at this moment, and I would be very upset if anything happened to her, which is why I have taken precautions for her safety if disaster strikes. However, things can happen in a disaster that should give us all cause for caution.

Any unfamiliar animal encountered after a disaster should be considered dangerous. They may seem harmless, but looks can be deceiving. Disasters (particularly weather-related) are incredibly distressing for an animal, and they can quickly revert back into their wild instincts. Even animals known to you to be friendly can bite or scratch in this state, so remain wary. As a long-time volunteer for an disaster animal rescue organization, I received intense training on handling animals like this, and I can tell you that those skills are not intutive or "obvious".

Weather-related disasters can bring an artificial introduction of wild or farm animals into areas domiciled by humans. Hurricane Katrina is perhaps the most dramatic example, with alligators, snakes and various creatures wandering on streets, buildings and homes.  Animal control in New Orleans even experienced a small spike in calls regarding bats that had taken refuge in abandoned buildings and residences.

Regardless, a professional exterminator should inspect the building before being reoccupied by your family or your business. If domesticated animals are discovered, animal control or the appropriate animal agency in your jurisdiction should be contacted.

3. Criminal Activity

Without question, the chaos and confusion of a disaster can be an easy predicator of increased criminal activity. Property and violent crime has a tendency to spike when civil authority is believed to be absent or “too busy” to respond.  If you notice a burglary or some other criminal activity taking place, contact law enforcement.

The immediate temptation in some places is to carry a weapon and confront a suspect directly. This is not wise, as this can lead to violence and bloodshed on both sides. Not only would lives be put at risk, but an incident of this type would only add additional burdens to EMS ambulance and law enforcement agencies trying to handle the disaster.

4. Biological Hazards

An immediate concern after a disaster is availability of food and water. And, unfortunately, after every disaster, I hear stories about people who became ill after consuming food left in damaged homes or businesses. Many believe that most food is “probably fine” when, in fact, it probably isn’t.


The bottom line is this: most food and drink left in a damaged home is inedible and should not be consumed.

First, all items in the fridge and freezer should not be eaten. Second, depending on the container, certain canned foods that remain on the shelf can be consumed later if they are properly cooked. This would depend on a lot of factors that, for reasons of space, cannot be listed here. However, in a future blog, I will discuss this in full detail. However, the general rule is:


When it doubt, throw it out.


It isn’t worth the risk of getting food poisoning like E. coli, Salmonella, or Ciguatera which could result in severe illness or even death. Spending a couple hundred dollars replacing food is better than having to spend time in the hospital or having a severe reaction to food or drinks that are unsafe for consumption.

5. Psychological Hazards  

Psychological hazards have come into greater focus for emergency responders in the last ten years. Last year I was a contributing author on a textbook for Advanced EMTs, and the chapter I wrote on disaster response had a good paragraph or two on psychological issues. And in a future blog I will write about it in more detail, because, unequivocally, that information can cross-apply to anyone returning after a disaster.

Be aware of yourself, and what you can and cannot handle.  

A disaster may bring out horrific, almost apocalyptic scenes of devestation. Homes and livelihoods may be completely destroyed, and people returning to view the destruction may be  emotionally distraught. Therefore, minimize your exposure. There is no reason (rational or otherwise) to “tour the damage” or look for injured victims. Let law enforcement, rescue personnel and EMS handle that. This will help prevent unnecessary distress on yourself and your family.

It is important to do a self-evaluation. Will scenes like this create a psychological hardship on you? Can you handle scenes of dead animals or people, destroyed buildings, distressed neighbors and friends? It’s ok if you can’t. It doesn’t mean you are “weak” or “spineless”. That recognition means you have taken an honest assessment of your psychological profile.

Conclusion

Safety after a disaster is paramount, because there are so many hazards that can be encountered. As a longtime emergency manager, and I can tell you that injuries resulting from these hazards can be deadly. Don’t take unnecessary risks.  Be safe as you proceed; this is the quickest route to Reverse Disaster. 

Patrick Hardy

www.hytropy.com

Twitter: @hytropy

Facebook: Hytropy