Nursing Home Emergency Preparedness Program (NH EPP) Self-Assessment

Nursing Home Emergency Preparedness Program (NH EPP) Self-Assessment

Distributed by the Alliant Health Solutions QIN-QIO Nursing Home Team

Name of Nursing Home*

Please populate the name of the nursing home.

CMS Certiﬁcation Number (CCN)*

CMS Certiﬁcation Number (CCN) – 6 digit identification number

Select

Street Address*

City*

State*

Zip*

Today's Date*

Please provide your First and Last name.*

Email Address*

Telephone Number*

Please provide a telephone number where you can be reached with any questions about your submission.

Phone

What is the job title of the person who oversees the Emergency Preparedness Program (EPP)?*

Emergency Preparedness Team*

Does your Emergency Preparedness Team include at least one member from each department of your facility, at least one member from each shift, at least one resident, and at least one family member?

Yes

Emergency Preparedness Team Composition Additions*

If no, who do you need to add? (i.e., a 3rd-shift staﬀ member, a resident, or a family member)

Select

Is your plan stored and easily accessible in at least two locations outside of your physical plant?*

i.e. in ED/DON car, downloaded on mobile devices, with a local emergency response coordinator

Yes

EPP Alignment with Facility Assessment*

Your EPP plan should be integrated and compatible with your facility assessment (F659). Is your EPP plan reviewed annually at the same time as your annual Facility Assessment?

Yes

Date of the most recent EPP Plan Review

Is a Hazard Vulnerability Assessment (HVA) completed annually and when signiﬁcant changes to your environment or operations occurs?*

Yes

Unsure

Hazard Vulnerability Assessment Support

If your HVA is overdue. Would you like the Alliant Health QIN-QIO Nursing Home team to assist you in reviewing the HVA?

Yes

Trauma-Informed Care*

Does your EPP address the provision of trauma-informed care and triggers for both residents and staﬀ from prior disasters?

Yes

Would you like the Alliant Health QIN-QIO Nursing Home team to contact you with resources and coaching support on trauma-informed care?*

Yes

EPP Testing Plan*

Does your testing plan include all of the following elements?

- Annual full-scale, functional or tabletop exercise

- Exercise scenarios based on risks identiﬁed in the HVA and facility assessment

- Post-exercise and small disaster (i.e., power outage) debrief with lessons learned and areas of opportunity for improvement

Yes

Most Recent Full-Scale or Tabletop Exercise

EPP Training Plan*

Does your training plan include all of the following elements?

- A process for random auditing (including oﬀ shifts and weekends) to assess if staﬀ are able to articulate their role in an emergency

- Process for training all staﬀ on any updates made to the plan

- Process for training all staﬀ, contracted staﬀ, and volunteers on the EPP include accessing the EPP and their roles in an emergency

- Documentation of all trainings

Yes

EPP Training Plan Support?*

Would you like the Alliant Health QIN-QIO Nursing Home team to contact you with resources and coaching support for addressing gaps in your training plan?

Yes

EPP Plan National Public Health Emergencies*

While facility plans may vary, there are national public health emergencies that apply to most, if not all, facilities. Does your plan address all of these public health emergencies?

- Infectious Disease Outbreaks

- Opioid Crisis

- Workplace Violence/Mass Trauma

Yes

EPP National PHE Support*

Infectious Disease Outbreaks

Opioid Crisis

Workplace Violence/Mass Trauma

No Resource Requested

Weather-Related Disasters*

Does your plan address each of these weather-related disasters from PHE.gov that are identiﬁed as risks to your facility in your HVA and facility assessment?

- Wildﬁres

- Hurricanes

- Tropical Storms

- Winter Storms

- Straight-line Winds

- Earthquakes

- Typhoons

- Tornadoes

- Floods

Yes

EPP Plan Components*

Does your EPP plan address all of the following elements?

- Clear delineation of staﬀ and volunteer roles in an emergency

- Plans to address staﬀing-level emergencies

- Equipment or supplies (medical and non-medical) needed for each type of emergency identiﬁed in the plan

- Staﬀing plan for extended/reduced hours, tasks that can be assigned to community volunteers

- Evacuation plans with multiple routes in anticipation of road closures, excess traﬀic

- Tracking system for on-duty staﬀ and sheltered residents

- Security and accessibility of medical record information in the event of loss of access to EHR

- Process for adjustments based on variations in census, case mix, and available staﬀing

- Continuity of operations plan

- Shelter-in-place operations

- At least two evacuation sites

- Management of an elopement based on your environment and immediate surroundings

Yes

Comments or Requests for Resources

Your Alliant Health Solutions QIN-QIO Nursing Home Team is available to provide resources and/or coaching as you develop and/or review your EPP Plans. Please list any additional disaster-related topics for which you would like to receive more information.

Send me a copy of my responses

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