Emergency Preparedness Program Sep 2017

October 9
Emergency
Preparedness
Program 2017
Kosciusko Home Care and Hospice, Inc.
EMERGENCY MANAGEMENT PROGRAM
Table of Contents
1. Kosciusko Home Care and Hospice, Inc. Emergency Management Program ........................................... 3
1.1 Background ......................................................................................................................................... 3
1.2 Emergency Management Program Mission and Priorities ................................................................. 3
1.3 Components of the Emergency Management Program ..................................................................... 3
1.3.1 Mitigation ..................................................................................................................................... 3
1.3.2 Preparedness ............................................................................................................................... 4
1.3.3 Response ...................................................................................................................................... 4
1.3.4 Recovery....................................................................................................................................... 5
1.4 Potential threats ................................................................................................................................. 5
1.4.1 Natural ......................................................................................................................................... 5
1.4.2 Manmade ..................................................................................................................................... 5
1.5 Definitions ........................................................................................................................................... 7
1.6 Scope of Agencys Emergency Management Plan for Disasters and Emergencies ............................ 8
1.6.1. Contents of the Emergency Management Plan .......................................................................... 8
2. Utilizing the Emergency Management Plan.............................................................................................. 9
2.1 Sequence of local disaster response. .................................................................................................. 9
2.1.1 Recognizing the disaster .............................................................................................................. 9
2.1.2 Activating the Emergency Management Plan.............................................................................. 9
2.1.3 Coordinating response ................................................................................................................. 9
2.1.4 Update local, State, and Federal authorities ............................................................................... 9
2.1.5 Activating agreements ................................................................................................................. 9
3 Emergency Management Plan ................................................................................................................. 10
3.1 Communication Plan ......................................................................................................................... 10
3.1.1 Phone tree.................................................................................................................................. 11
3.1.2 Facebook page ........................................................................................................................... 11
3.1.3 Delegation of Authority ............................................................................................................. 11
3.1.4 Cooperation and Collaboration with local, State, and Federal Authorities ............................... 11
3.2 Communications Plan Decision Tree................................................................................................. 13
PUB.EMERGENCY PREPAREDNESS PROGRAM Page 1 of 32

3 Phone Tree ........................................................................................................................................... 14

3.2 Continuity of Services Plan................................................................................................................ 15
3.2.1 Patient Contact .......................................................................................................................... 15
3.2.2 Evacuations ................................................................................................................................ 15
3.2.3 Caregiving................................................................................................................................... 17
3.2.4. Travel ban.................................................................................................................................. 17
3.2.5 Surge capacity ............................................................................................................................ 18
3.2.5 Agency Emergency Codes: ......................................................................................................... 19
3.2.6 Continuity of Patient Services Flow Chart.................................................................................. 21
3.2.7 Patient Contact Process-Case Manager ..................................................................................... 21
3.2.8 Patient Contact Process-Supervisors ......................................................................................... 22
3.3 Business Continuity and Recovery Plan ............................................................................................ 24
3.3.1 Building integrity ........................................................................................................................ 24
3.3.2 Crime Scene ............................................................................................................................... 24
3.3.3 Credible Threat/Active Shooter ................................................................................................. 24
3.3.4 Bomb Threat .............................................................................................................................. 26
3.3.5 Server Connectivity Issues ......................................................................................................... 27
3.3.6 Data risks and loss ...................................................................................................................... 27
3.3.7 Server Connectivity Plan ............................................................................................................ 28
3.3.8 Off-site protocol ......................................................................................................................... 29
4 Training and Testing ................................................................................................................................. 30
4.1 Training Program............................................................................................................................... 30
4.2 Testing Program ................................................................................................................................ 30
Contact List ................................................................................................................................................. 31

1. Kosciusko Home Care and Hospice, Inc. Emergency Management

Program
1.1 Background
The mission of Kosciusko Home Care and Hospice, Inc. is to make a positive difference in the lives of
those we serve, to treat all individuals with integrity, compassion, and respect, and to deliver the highest
quality of home health care and hospice services to those in need. This mission becomes even more
essential in the throes of a disaster or emergency. The Agency is committed to the preservation of life,
the delivery of the highest quality healthcare, and the continuity of patient and business services
throughout all stages of a disaster or emergency.
Refer to Agency Mission, Vision, and Values.
The Agency is also committed to abiding by all applicable laws pertaining to emergency preparedness.
Refer to Emergency Preparedness Program Policy and Procedure.
1.2 Emergency Management Program Mission and Priorities

Protection of life.
Continuity of patient services .
Collaboration and coordination with local, State, and Federal authorities and other agencies.
Business continuity.
1.3 Components of the Emergency Management Program
1.3.1 Mitigation
Mitigation includes actions taken to eliminate or reduce the degree of long-term risk to human life,
property, and the environment. Mitigation measures include assessing risk, monitoring and inspecting,
educating and training. The Agency has policies and procedures, technical, and physical safeguards to
reduce risks encountered in day-to-day operations.
Refer to Agency Bomb Threat Policy and Procedure.
Refer to Agency Building Safety and Security Management Policy and Procedure.
Refer to Agency Emergency Evacuation Policy and Procedure.
Refer to Agency Fire Prevention and Safety Policy and Procedure.
Refer to All-Hazards Vulnerability Risk Assessment Policy and Procedure.

Refer to Credible Threat/Active Shooter Policy and Procedure.

Refer to Device and Media Control Policy and Procedure.
Refer to Electronic Communications and Internet Usage Policy and Procedure.
Refer to Login and Password Management Policy and Procedure.
Refer to Protection Against Malicious Software Policy and Procedure.
Refer to Supervision of Outside Workforce Policy and Procedure.
Refer to Tornado/Watch/Warning/Direct Hit Policy and Procedure.
1.3.2 Preparedness
Preparedness includes actions taken in advance of an emergency to evaluate operational capabilities
and facilitate an effective response in the event of an emergency. The Agency has an extensive
Emergency Preparedness Program that includes an Emergency Management Plan that is reviewed,
tested, and updated at least annually. Staff is trained annually on the contents of the Emergency
Management Plan. Upon admission to home care and hospice services, patients and families are
educated to develop their own emergency management plan. The Agency will participate in an annual
full-scale and tabletop exercise with regular collaboration with local, State, and Federal emergency
management officials and other outside agencies.
Refer to Emergency Management Plan Policy and Procedure.
Refer to Communications Plan Policy and Procedure.
Refer to All-Hazards Vulnerability Risk Assessment Policy and Procedure.
Refer to Emergency Management Plan Training and Testing Policy and Procedure.
1.3.3 Response
Response includes actions taken immediately before, during, and after a disaster or emergency to save
lives, protect property, to minimize long-term effects of the emergency, and to enhance recovery
efforts. Response is enacted according to the Agencys Emergency Management Plan and in accordance
with and as directed by local, State, and Federal authorities.
Refer to Communication Plan Policy and Procedure.

1.3.4 Recovery
Recovery includes actions taken to return the organization to pre-disaster operational levels. Once the
immediate phase of an emergency or disaster has concluded, the focus shifts from emergency
management to recovery efforts. The Agency may need to relocate, rebuild, re-establish community
presence, and/or regain community trust.
Refer to Business Continuity and Recovery Plan.
1.4 Potential threats

Though natural and man-made disasters or emergencies are rare, they do occur. The federal
government has enacted regulations to ensure that the healthcare system is prepared to face disasters
and emergencies and to respond effectively.
The Agency has determined the most likely disasters or emergencies the Agency and surrounding area
based on situational and available historical data. This is not to say that other disasters or emergencies
will not occur, just that they may not be as likely to occur.
Refer to All-Hazards Vulnerability Risk Analysis Policy and Procedure.
Refer to current All-Hazards Vulnerability Risk Analysis.
1.4.1 Natural
Due to the Agencys location in Northern Indiana, the greatest threats to Agency operations are from
the following:
Tornado.
Blizzard, significant snowfall.
Ice storm.
Power outage.
Severe thunderstorm.
Flooding.
1.4.2 Manmade
Due to the Agencys building location in the urban area of Warsaw, Indiana, as well as the rural
conditions of the patient population in Kosciusko County, the greatest threats to Agency operations are
from the following:

Electrical or communications failure.

Factory, facility fire, or explosion.
Chemical exposure.
Large-scale vehicular disaster.
Epidemic.
Due to the use of electronic devices and/or connection to the Internet, other threats to Agency
operations are from the following:
Business data loss.
Unauthorized exposure or loss of protected health information.
Due to the nature of the business and activity of other tenants in the K21 Health Services Pavilion, other
threats to the Agency operations are from the following:
Credible threat/active shooter.
Bomb threat.

1.5 Definitions
Disaster-A hazard impact causing adverse physical, social, psychological, economic or political
effects that challenges the ability to respond rapidly and effectively. Despite a stepped-up
capacity and capability (call-back procedures, mutual aid, etc.) and change from routine
management methods to an incident command/management process, the outcome is lower
than expected compared with a smaller scale or lower magnitude impact (Indiana District 2
Emergency Preparedness Handout, 2017).
Emergency-A hazard impact causing adverse physical, social, psychological, economic or
political effect that challenges the ability to respond rapidly and effectively. It requires a
stepped-up capacity and capability (call-back procedures, mutual aid, etc.) to meet the expected
outcome, and commonly requires change from routine management methods to an incident
command process to achieve the expected outcome (Indiana District 2 Emergency
Preparedness Handout, 2017).
Emergency preparedness program-Describes a facilitys comprehensive approach to meeting
the health, safety, and security needs of the facility, its staff, their patient population and
community prior to, during, and after an emergency or disaster (Indiana District 2 Emergency
Emergency management plan-Provides the framework for the emergency preparedness
program. The emergency plan is developed based on facility-and community-based risk
assessments that assist a facility in anticipating and addressing facility, patient, staff and
community needs and supports continuity of business operations (Indiana District 2 Emergency
All-hazards approach-An integrated approach to emergency preparedness that focuses on
identifying hazards and developing emergency preparedness capacities and capabilities that can
address those as well as a wide spectrum of emergencies or disasters. This approach includes
preparedness for natural, man-made, and or facility emergencies that may include but is not
limited to care-related emergencies; equipment and power failures; interruptions in
communications, including cyber-attacks; loss of a portion or all of a facility; and interruptions in
normal supply of essentials, such as water and food (Indiana District 2 Emergency

1.6 Scope of Agencys Emergency Management Plan for Disasters and

Emergencies
Though every disaster scenario cannot be anticipated, the Emergency Management Plan takes an all-
hazards approach and can be utilized and adjusted for most scenarios that may be encountered. The
plan addresses communications, continuity of patient services, business continuity and recovery,
evacuation, and training and testing.
1.6.1. Contents of the Emergency Management Plan

Communications
The Communication Plan of the Emergency Management Plan addresses communicating with
employees of the Agency, current patients in all programs, local, State and Federal authorities,
business contacts and vendors, as well as media outlets.
Continuity of services
The Emergency Management Plan addresses how patients will be triaged, how needs will be
met, evacuations, and other patient related services.
Business continuity and recovery
The Emergency Management Plan addresses how critical business operations will continue, data
recovery process, as well as the spiritual and psychosocial needs of patient and staff members.
Evacuation
The Evacuation plan addresses movement of employees in the building at the time of a disaster
or emergency, as well as evacuations of patients.
Training and testing
The training and testing plan addresses how employees will be trained and educated on the
Emergency Management Plan, as well as the annual review process, tabletop and full scale
exercises.

2. Utilizing the Emergency Management Plan

2.1 Sequence of local disaster response.
1. Recognizing the disaster.
2. Activating the Emergency Management Plan.
3. Coordinating the response with public and private organizations and agencies.
4. Updating the applicable local, State, and Federal authorities.
5. Activating agreements with State and Federal departments or agencies and private
organizations.
2.1.1 Recognizing the disaster

Each and every employee plays a part in safeguarding life, maintaining continuity and protecting
business assets in an emergency or disaster. The key to early and effective response is early recognition
of a disaster or emergency to reduce long-term effects.
2.1.2 Activating the Emergency Management Plan

Once an employee recognizes an emergency or disaster, that employee is to immediately notify the
Administrator or designee. Only the Administrator or designee can activate the Emergency Management
Plan.
2.1.3 Coordinating response

Once the Emergency Management Plan has been activated, the Administrator or designee is responsible
for coordinating the response with public or private organizations or agencies.
2.1.4 Update local, State, and Federal authorities

The Administrator or designee is responsible for updating all necessary local, State, and Federal
authorities.
2.1.5 Activating agreements

The Administrator or designee is responsible for activating all agreements with local, State, and Federal
authorities or agencies and private organizations.

3 Emergency Management Plan
3.1 Communication Plan

It is imperative to maintain good communication throughout any disaster or emergency. All employees
must ensure that any and all communications are accurate, timely, and reliable. Supervisors must
enforce strict adherence to the phone tree to reduce rumors or unreliable information spread to
employees or the community.
Refer to 3.2 Communication Plan Decision Tree.
The Communications Plan will include the following:

1. Names and contact information for the following:
a. Staff.
i. Employee list in Emergency Preparedness Manual.
ii. Electronic database.
b. Entities providing services under arrangement.
i. Entities list in Emergency Preparedness Manual.
c. Patients Physicians.
i. Face sheets in Emergency Code patient manual.
d. Volunteers.
i. Employee list in Emergency Preparedness Manual.
2. Contact information for the following:
a. Federal, State, tribal, regional, and local emergency preparedness staff.
b. Other sources of assistance.
All employees will maintain written or electronic documentation of all information passed between
employees, as well as directions from local, State, and Federal authorities, requests for help or
assistance from employees, and updates on the progression of the recovery process. The
documentation will include the time, date, name of person contacted, type of communication (phone
call, text, etc.) information that was given or received, as well as any other pertinent data pertaining to
the communication.

A list will be maintained of all staff members that are unable to be reached during a disaster or
emergency. The Administrator or designee will be prepared to provide this information to local, State,
and Federal authorities, as requested.
3.1.1 Phone tree

The phone tree will serve as the communication protocol for communication flow in the event of a
disaster or emergency. Communication with media, social, and community outlets will be limited to the
Administrator or designee only. All employees will refer any communication requests from media
outlets to the Administrator or designee.
Refer to 3.3 Phone Tree.
3.1.2 Facebook page

Kosciusko Home Care and Hospice, Inc. employee Facebook page (KHCH employees) is a closed
Facebook group that is administrated by the Administrator, Director of Operations, and Office Manager.
The Facebook page will be updated monthly by the Office Manager and as needed by the Admins in the
event of a disaster or emergency. No patient information will be passed on this site as the site is
unsecured.
3.1.3 Delegation of Authority

Delegation of authority and supervision will follow the current organizational chart.
Refer to current organizational chart.
3.1.4 Cooperation and Collaboration with local, State, and Federal Authorities
The Administrator or designee is solely responsible for coordinating and communicating with local,
State, and Federal authorities in the midst of a disaster or emergency. Supervisors will update the
Administrator no less than hourly as to any changing patient and Agency conditions or requirements.
The Administrator or designee will then update the authorities as appropriate via telephone (primary
method) or email (secondary method), and document all communication with the local, State, and
Federal authorities.
The Administrator or designee will communicate the following to local, State, and Federal authorities:
1. Condition and location of employees, as requested.

2. On-duty staff or patients that the Agency is unable to contact, as requested.

3. Agency needs.
4. Agencys ability to provide assistance.
The Agency will maintain a relationship with the Indiana District 2 Healthcare Coalition Preparedness
Alliance, composed of the Healthcare Coalition (HCC) and the District 2 Planning Council (DPC) by
accomplishing the following:
Attending District 2 Healthcare Coalition Preparedness Alliance meetings (Security Officer).

Attending applicable online and in-person training events (Security Officer).
Receiving email updates from the HCC and the DPC.
Participating in full-scale and tabletop exercises, as appropriate.

3.2 Communications Plan Decision Tree
Agency phones are

not operable.
Utilize personal
and Agency cell Update answering
Initiate phone tree
phones for service
communication
Utilize on-call
If unavailable, see beepers for all
below. incoming Agency
phone calls.
Cell phone
service is
unavailable
Communicate
via KHCH Utilize available Update staff via
Employee landlines WRSW 107.3FM
facebook page
Use employee
list for landline
listings

3 Phone Tree
Local, state, and

Federal
authorities
Administrator
Director of
Security Officer
Operations
Home Health Nurse

Office Manager Quality Assurance
Manager
Billing Assistant Public Relations Home Health Staff
HHA/HMK
Office Assistant
Coordinator
HHA/HMK staff
Hospice staff
Vounteer
Coordinator
Volunteers
Medication and
Board of Directors
Dental Assistance

3.2 Continuity of Services Plan

3.2.1 Patient Contact
Upon admission, all patients are prioritized for risk and assigned an Agency Emergency Code. This code
is documented on the face sheet and the appropriate colored name label is placed on the binder of the
hard chart. Case managers are responsible for making changes in the emergency code status of their
patients and updating the chart. Copies of the patient face sheets are kept in a specified binder,
organized by Agency Emergency Codes. The books will be kept in the possession of the Director of
Operations or designee and the Home Health Nurse Manager. The Agency codes will be used to
prioritize patient contact/visits in the event of a disaster or emergency.
Refer to 3.2.5 Agency Emergency Codes.
Once a disaster or emergency is declared by the Administrator or designee, supervisors will instruct all
on-duty case managers to contact their assigned patients within a given time frame. Patients will be
contacted based on location of the disaster/emergency, as well as the Emergency Code assigned to the
patient. Patients of off-duty case managers will be assigned to other case managers by the supervisor.
Case managers will document, in written or electronic form, the time, date, method of contact, name of
the patient, condition of the patient, patients residence, condition of the caregiver, visit needs, supply
and medication needs, evacuation needs, etc. Once patients are contacted, Emergency Codes will be
adjusted as appropriate. Supervisors will be notified by the case managers of the patient condition,
needs, etc. Supervisors will be responsible for communicating with DME providers, pharmacies, and
ambulance services.
Supervisors of both programs will develop a list of patients that case managers are unable to reach. The
Administrator or designee will be prepared to communicate the list of uncontacted patients with local,
State, and Federal authorities.
Supervisors will assign patient visits based on compiled case manager reports and adjust as situations
change.
Refer to 3.2.6 Continuity of Patient Services Flow Chart.

Refer to 3.2.7 Patient Contact Process-Case Manager.
Refer to 3.2.8 Patient Contact Process-Supervisor.
Refer to Home Health Admission Policy and Procedure.
Refer to Hospice Admission Policy and Procedure.
Copy of the consents for each program?
3.2.2 Evacuations
3.2.2.a Patient Evacuations

It may be necessary for patients to be transported to other care or living arrangements, such as
emergency rooms, emergency shelters, family member homes, nursing homes or assisted living
arrangements. Patients may need to be discharged to other services or health organizations

during the emergency or disaster. Case managers will need to chart the location, contact
information, agency, etc., of any changes to a patients location and communicate that
information with supervisors. The Administrator or designee will be prepared to communicate
that information with local, State, and Federal authorities, as requested.
Supervisors will be responsible for initiating and coordinating the Patient Evacuation Plan. Under
no circumstances will patients be transported in employee vehicles.
3.2.2.a(1) Patient Evacuation Plan
Patient Evacuation
Home Care Hospice
Non- Non-
Ambulatory/Able to Ambulatory/Able to
ambulatory/Unable to ambulatory/Unable to
travel by personal travel by personal
travel by personal travel by personal
vehicle vehicle
vehicle vehicle
Move patient via Coordinate with Move patient via Coordinate with
personal vehicle emergency services personal vehicle emergency services

3.2.2.b Employee Evacuations

It may be necessary for employees to be evacuated from the Agency due to a disaster or
emergency. The Administrator or designee, in conjunction with K21 Health Services Pavilion
Management team, local, State, and Federal authorities, will make the final decision to evacuate
the facility.
Building Damage
In the event the building is damaged or destroyed, employees are to contact 9-1-1 to report the
emergency, evacuate staff and visitors from the damaged portion of the building, gather at the
southwest corner of the Pavilion parking lot, administer First Aid to the injured, and await
further instructions.
Refer to Agency Emergency Evacuation Policy and Procedure.
Tornado Watch
In the event of a tornado watch, the Administrator or designee will monitor the situation.
Off-site staff will monitor the situation and take appropriate precautions to maintain personal
safety.
Tornado Warning
In the event of a tornado warning, the Administrator or designee will immediately notify the
Agency employees and visitors of the need to move to the Safety Zone located in the interior
offices of the southwest corner of the building, first floor. If individuals are unable to get to the
designated Safety Zone, they are to take shelter in an interior office area with no windows.
Employees are not permitted to leave the area until the all-clear has been given by the Agency
Administrator, designee, local law enforcement , or emergency services personnel.
Off-site staff will monitor the current situation and take appropriate precautions to maintain
personal safety.
Refer to Tornado Watch/Warning/Direct Hit Policy and Procedure.
3.2.3 Caregiving
Employees will need to keep in mind that the Agency is not equipped to become primary caregivers for
any of the patients. It may become necessary to assist them in finding other caregiving options, but the
Agency does not replace the need for a primary caregiver. A Red Cross shelter map can be found at
redcross.org.
The Agency will be prepared to accept additional patients, as necessary and able.
3.2.4. Travel ban

If the Agency deems it necessary for employees to be travelling in spite of a travel ban, the
Administrator or designee will need to notify local, State, and Federal authorities to obtain special

permission. Agency employees may be required to carry both a state-issued ID and their Agency ID to
gain access.
3.2.5 Surge capacity

Surge capacity will be determined by the scope and location of the disaster or emergency. The Agency
has limited capacity to accept new patients based on the size of the organization and the current
staffing. Surge capacity ability will be determined by the Administrator or designee and communicated
to local, State, and Federal authorities.

3.2.5 Agency Emergency Codes:

A. CODE 1 (Salmon): First priority. The absence of daily medical care by a skilled professional within the
first twenty-four (24) hours poses an immediate threat to life.
Examples: Ventilator or oxygen-dependent (greater than 2 Liters), patient without a capable caregiver,
infusion or other therapy critical for life, dependent on electricity.
B. CODE 2 (Blue): Second priority. The absence of daily medical care service does not pose an
immediate threat to life, but patient will require care by a skilled professional within forty-eight (48) to
seventy-two (72) hours.
Examples: Daily wound care or daily injection without a capable caregiver, continuous oxygen @1-2
Liters, total care/bedbound patient with high risk for complications.
C. CODE 3 (Yellow): Third priority. The absence of medical care services does not pose an immediate
threat to life, but patient may require care within seventy-two (72) to ninety-six (96) hours.
Examples: Unstable, chronic illness, intermittent wound care or other condition that requires skilled
intervention every week.
D. CODE 4 (Green): Final priority. Care usually required every two (2) to four (4) weeks.
Examples: Monthly, catheter care, patient residing in assisted living facilities or nursing homes.

CODE Definition Examples

SALMON- The absence of daily medical care by a skilled Ventilator or oxygen-dependent (greater than 2
first priority professional within the first twenty-four (24) hours Liters, patient without a capable caregiver,
poses an immediate threat to life infusion or other therapy critical for life,
dependent on electricity
BLUE- The absence of daily medical care service does not Daily wound care or daily injection without a
second pose an immediate threat to life, but patient will capable caregiver, continuous oxygen @1-2
priority require care by a skilled professional within forty- Liters, total care/bedbound patient with high risk
eight (48) to seventy-two (72) hours. for complications.
YELLOW- The absence of medical care services does not pose Unstable, chronic illness, intermittent wound
third priority an immediate threat to life, but patient may require care or other condition that requires skilled
care within seventy-two (72) to ninety-six (96) hours. intervention every week
GREEN-final Care usually required every two (2) to four (4) weeks. Monthly, catheter care, patient residing in
priority assisted living facilities or nursing homes.

3.2.6 Continuity of Patient Services Flow Chart
Emergency/Disaster Patients triaged

Supervisors assign
declared by based on contact
patient contact
Administrator results
3.2.7 Patient Contact Process-Case Manager

Patient contact
by location and
priority code
Notify
Assess needs
supervisor
Assign priority
3.2.8 Patient Contact Process-Supervisors
Assign patient
contact to case
managers

Compile patient
contact results
Coordinate supply Assign patient

drops visits
Initiate Patient
Evacuation Plan
as needed.
Coordinate with
Coordinate with
emergency
outside health
managment
services
services
Contact DME,
pharmacy
providers, utilities
Update
administrator

3.3 Business Continuity and Recovery Plan

The Business Continuity and Recovery Plan ensures that the Agency will operate at its greatest potential
during a disaster or emergency, experience the least amount of disruption, and return to full operational
capacity as quickly as possible.
3.3.1 Building integrity

The Agency rents a space within the K21 Building and is, therefore, not tasked with the responsibility of
addressing building or structure issues. In the event of any building or structure issues, the K21 Health
Services Pavilion Management Team will be contacted and will address any issues as outlined in the K21
Health Services Pavilion Employee/Tenant Handbook.
Refer to K21 Health Services Pavilion Employee/Tenant Handbook.
If an employee notes any issues with the building structure or integrity, notify the Administrator or
designee and that individual will contact the K21 Health Services Pavilion Management Team.
3.3.2 Crime Scene

In the event of a crime, an employee is to notify the appropriate law enforcement personnel. The
employee is to then contact the Administrator or designee and that individual will contact the K21
Health Services Pavilion Management Team.
Refer to Crime Scene Policy and Procedure.
3.3.3 Credible Threat/Active Shooter

Refer to Credible Threat/Active Shooter Policy and Procedure.
3.3.3a Definitions:
Hostile intruder: An armed individual (knife, gun, etc.) on the premises and threatening
harm to employees, visitors, and/or other building occupants.
Credible threat received or suspected: A phone call made or letter/email sent to the
HSP threatening to cause harm or personal life circumstances of an employee or visitor
that gives justifiable concern that a threat exists. Any employee with personal life
circumstances that might lead to a violent encounter at work or any employee aware of
someone elses situation that might lead to violence at work is expected to notify an
appropriate member of management immediately.
Lockdown: The steps taken to ensure the safety and security of building occupants
during a violent incident or the possibility of a violent incident.
3.3.3b Procedure
Regardless of the location, the initial response to a violent incident is the same, although the
person responsible for performing these steps will vary. In any event, these steps MUST occur as
quickly as possible.
1. Initial response to credible threat/active shooter.
a. If you observe a violent incident, do NOT confront the individual. If at all
possible, attempt to move calmly away from the individual.

b. If you are in an HSP interior office, attempt to call the HSP receptionist and
report the situation. If the HSP receptionist does not respond quickly, use the
phone system to request the HSP receptionist or a member of management call
your extension STAT. Provide the HSP receptionist or caller with as much
information as possible.
i. Location of the individual.
ii. Direction the individual is moving, if known.
iii. Description of weapons.
iv. Any known injuries and locations of victims.
v. Any threats made by the individual.
c. The HSP receptionist or management team member is responsible to announce
Initiate Lockdown three (3) times over the phone system.
d. After announcing a lockdown, the HSP receptionist or management team
member will notify police and pass along as much information as is known. If
possible, the person will stay on the line until police terminate the call.
e. After calling police, the Initiate Lockdown announcement will be made three
(3) additional times by the HSP receptionist.
f. Once a lockdown is underway, employees and visitors should not move about
the building until the all-clear is given by police or a designated member of
management over the phone system.
2. Lockdown initiated.
a. If able to do so safely, the Agency receptionist or front office staff will lock the
front Agency door.
b. All Agency employees and visitors must move to an area(s) that can be locked,
remain out of sight of windows and doors, and assume a protected prone
position (suggested sites: interior offices on north hall)
c. Call 911 to notify police of your location.
d. Remain sheltered-in-place until the all-clear is given by police or a designated
member of management over the phone system.
3. Credible threat perceived.
a. If a threat exists but is not deemed imminent, the response may vary.
i. During regular building hours, any perceived threat is to be reported
immediately to a supervisor or upper management, who will assess the
situation and consider any and all of the following options:
1. Contact and consult police.
2. Consult with the Management Response Team.
3. Initiate a lockdown, if appropriate.
ii. After regular building hours, the responsibility to respond to a perceived
threat will rest largely at the discretion of the employee. However, if
there seems to be any credibility to the perceived threat, the employee
should err on the side of caution and consult with the police.

3.3.4 Bomb Threat

Refer to Bomb Threat Policy and Procedure.
1. Threat by phone.
a. Remain calm. Keep the caller on the phone as long as possible. DO NOT HANG UP, even
if the caller does.
b. Listen carefully. Be polite and show interest.
c. Try to keep the caller talking to learn more information.
d. If possible, write a note to a colleague to call local law enforcement or, as soon as the
caller hangs up, immediately notify them yourself.
e. If your phone has a display, copy the number and/or letters on the window display.
f. Complete the Telephone Procedures Checklist.
g. Notify your supervisor.
h. Initiate evacuation procedures per the Emergency Evacuation Plan, if indicated by local
law enforcement or your supervisor. DO NOT USE ANY LIGHTS, TWO-WAY RADIOS, OR
CELLULAR PHONES PRIOR TO EVACUATING THE BUILDING. Radio signals have the
potential to detonate a bomb.
2. Threat by mail.
a. Call local law enforcement.
b. Notify your supervisor.
c. If a note, handle the note as minimally as possible.
d. DO NOT TOUCH OR MOVE A SUSPICIOUS PACKAGE.
e. Initiate evacuation procedures per the Emergency Evacuation Plan. DO NOT USE ANY
LIGHTS, TWO-WAY RADIOS, OR CELLULAR PHONES PRIOR TO EVACUATING THE
BUILDING. Radio signals have the potential to detonate a bomb.
3. Threat by e-mail.
a. Call local law enforcement.
b. Notify your supervisor.
c. DO NOT DELETE THE MESSAGE.
d. Initiate evacuation procedures per the Emergency Evacuation Plan. DO NOT USE ANY
LIGHTS, TWO-WAY RADIOS, OR CELLULAR PHONES PRIOR TO EVACUATING THE
BUILDING. Radio signals have the potential to detonate a bomb.
4. Signs of a suspicious package.
a. No return address; excessive or foreign postage
b. Unexpected delivery
c. Stains, strange odor or sounds
d. Poor handwriting, misspelled words, or incorrect titles
5. DO NOT allow anyone to re-enter the building. Only law enforcement may enter the building to
search for the bomb.
6. No radio or electrical equipment inside the facility will be used between receiving the bomb
threat and all clear is announced.
7. Do not return to the building until law enforcement has given the all clear announcement.
8. Document the incident in an Incident Report.

3.3.5 Server Connectivity Issues
General Information
Per conversation with Mike Shira (Intrasect) on 8/22/17:
Current database can be virtualized from anywhere with a computing device as database is
cloud-based, encrypted, stored on-site in two locations that are on both coasts of the U.S.
The server can be accessed in approximately 2 hours, if necessary, from any computing device.
If virtualizing the server, connectivity speed will largely be based on internet availability and
speed, and users will be limited in number. Data and applications are continuously backed up
and will be available.
Approximately 2 weeks to order and rebuild the server. Highly dependent on building
configuration and capabilities.
Approximately $100,000 to rebuild current office IT equipment, labor is intensive and expensive
(2017 costs, expect costs to continue to rise).
Downloads to the billing service require large amounts of data. In the event that the server is virtualized,
an external hard drive may be required.
3.3.6 Data risks and loss

Due to the technologically connected world that we live in today, data loss is a constant threat from
inside and outside risks. Data can become compromised from software, hardware, email attachments,
malicious intent, downloads, and many other sources. The Agency has policies and procedures to
protect patient and business data. Employees will be educated annually regarding the standards of
conduct and the sanctions and risks associated with improper behavior.
Refer to Data Continuity and Backup Plan Policy and Procedure.
Refer to Electronic Communications and Electronic Usage Policy and Procedure.

3.3.7 Server Connectivity Plan
Unable to
Contact IT
connect to Provider
server
Staff members
Notifications Billing service
Schedule laptop
Mobile device downloads
Schedule billing
to connect to downloads
Cloud Notice of Election
inputs
Purchase
Set up new equipment
server Installation by
IT Provider

3.3.8 Off-site protocol

In the event of an emergency or disaster, the Administrator, in conjunction with building management,
local, State, and Federal authorities, will determine if the off-site protocol is to be enacted. Staff
members will be notified in accordance with the Communication Plan.
The Administrator or designee will determine a temporary business location until a permanent solution
can be located. Staff members will be immediately notified of the alternate location in accordance with
the Communication Plan. The Director of Operations will coordinate with Office Staff members to
contact business entities and organizations that provide supplies or services to the Agency. These
businesses will be advised to change or cease services to the current address and notified of the change
of location and changing needs.
The Security Officer will contact the Internet Provider to initiate new information technology setup, as
appropriate.
Once a permanent location has been selected, the Director of Operations will coordinate with Office
Staff members again to contact business entities and organizations that continue to provide supplies
and services to the Agency at the temporary location. These businesses will be advised of the
permanent change of address and changing needs.
Potential Off-Site Locations

1. Local: Redpath-Fruth Funeral Home
Internet capabilities-yes
Generator-no
Proximity to Agencys current location
2. Pierceton: McHatton-Sadler Funeral Home

Internet capabilities-no
Generator-located at Warsaw branch
Proximity to Pierceton Fire Department
3. North-Mischler-Eastlund Funeral Home-pending approval by funeral home

Internet capabilities-unknown
Generator-unknown
Proximity to major road

4 Training and Testing

The greatest emergency management plan can look great on paper, but what really matters is how it
performs under trying circumstances. Training provides the opportunity for staff members to become
familiar with the contents of the Emergency Preparedness Program without the stress of a real disaster
or emergency, while testing provides the opportunity to enact the Emergency Management Plan under
simulated conditions.
4.1 Training Program

The Agency will provide initial training in emergency preparedness policies and procedures, to all new
and existing staff, individuals providing service under arrangement and volunteers, consistent with their
expected role.
The Agency will provide emergency preparedness training at least annually, maintain documentation of
the emergency preparedness training, and demonstrate staff knowledge of emergency procedures.
4.2 Testing Program

The Agency will conduct exercises to test the Emergency Management Plan at least annually and will do
all of the following:
1. Participate in a full-scale exercise that is community-based or when a community-based exercise
is not accessible, an individual facility-based.
a. If the Agency experiences an actual natural or man-made emergency that requires
activation of the emergency plan, the Agency is exempt from engaging in a community-
based or individual, facility-based exercise for one (1) year following the onset of the
actual event.
2. Conduct an additional exercise that may include, but it not limited to the following:
i. A second full-scale exercise that is community based or individual, facility-based.
ii. A tabletop exercise that includes a group discussion led by a facilitator, using a
narrated, clinically-relevant emergency scenario, and a set of problem statements,
directed messages or prepared questions designed to challenge an emergency plan.
3. Analyze the Agencys response to and maintain documentation of all drills, tabletop exercise,
and emergency events, and revise the Agencys emergency plan, as needed.

Contact List
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3 Phone Tree ........................................................................................................................................... 14

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1. Kosciusko Home Care and Hospice, Inc. Emergency Management

1.2 Emergency Management Program Mission and Priorities

1.3 Components of the Emergency Management Program

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Refer to Credible Threat/Active Shooter Policy and Procedure.

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1.4 Potential threats

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Electrical or communications failure.

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1.6 Scope of Agencys Emergency Management Plan for Disasters and

1.6.1. Contents of the Emergency Management Plan

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2. Utilizing the Emergency Management Plan

2.1.1 Recognizing the disaster

2.1.2 Activating the Emergency Management Plan

2.1.3 Coordinating response

2.1.4 Update local, State, and Federal authorities

2.1.5 Activating agreements

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3 Emergency Management Plan

3.1 Communication Plan

The Communications Plan will include the following:

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Refer to Communication Plan Policy and Procedure.

3.1.1 Phone tree

3.1.2 Facebook page

3.1.3 Delegation of Authority

Refer to current organizational chart.

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2. On-duty staff or patients that the Agency is unable to contact, as requested.

Attending District 2 Healthcare Coalition Preparedness Alliance meetings (Security Officer).

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3.2 Communications Plan Decision Tree

Agency phones are

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Local, state, and

Home Health Nurse

Billing Assistant Public Relations Home Health Staff

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3.2 Continuity of Services Plan

Refer to 3.2.5 Agency Emergency Codes.

Refer to 3.2.6 Continuity of Patient Services Flow Chart.

3.2.2.a Patient Evacuations

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3.2.2.a(1) Patient Evacuation Plan

Home Care Hospice

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3.2.2.b Employee Evacuations

3.2.4. Travel ban

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3.2.5 Surge capacity

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3.2.5 Agency Emergency Codes:

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CODE Definition Examples

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3.2.6 Continuity of Patient Services Flow Chart