1. Preparing for a Pandemic Event Developing a Continuity of Operations Plan (COOP) Presented by: Scott Aronson, MS 860-793-8600 / www.phillipsllc.comwww.phillipsllc.com

2. Implementation Goals NOT Flu Pandemic Diagnosis/Treatment NOT Flu Pandemic Diagnosis/Treatment Why Dialysis, Nursing Home, Home Health? Why Dialysis, Nursing Home, Home Health? Detail Approaches for a COOP Detail Approaches for a COOP Communications & Incident Management Communications & Incident Management Staffing Plan/Education Staffing Plan/Education Supplies/Resources Supplies/Resources Transportation Transportation Facilities/Engineering Facilities/Engineering Clinical Services / Strategies Clinical Services / Strategies Utilizing Mutual Aid to Supplement Planning Utilizing Mutual Aid to Supplement Planning Review Effective Exercises Review Effective Exercises

3. Are You Really Prepared for a Disaster? Are You Really Prepared for a Disaster? The Emergency Managers Problem

4. $ Money $ Regulation/ Statutes Fear Ethics

5. Nursing Home Higher Level of Flu Reported in Connecticut Hospitals See Patient Surge – Increase Discharges Home Health Dialysis Beds Full and Resident Acuity at Higher Level Provide Short Term Surg to Assist Discharging Hospital Patients Higher Acuity on Dialysis Patients Now At Home / Transportation Failures Staffing Impact Increases and Influenza Pandemic Clearly Identified Why Dialysis, Home Health & Nursing Homes

6. Emergency Operations Plan (EOP) and Continuity of Operations Plan (COOP) EOP actions are procedural and taking place as the event unfolds (i.e. Bomb Threat, Building Evacuation) COOP is how you ensure the ability to operate your organization throughout any disaster – special emphasis on Influenza Pandemic Challenge: Limited to No Incident Command System training (Communication/Redundancy) Challenge: Emergency responders and State are a resource…do not make them your plan

7. Stand Alone Currently Joint Commission, but NFPA to follow with CMS Currently Joint Commission, but NFPA to follow with CMS Stand Alone for 96 Hours + in 6 critical area Stand Alone for 96 Hours + in 6 critical area Communications Communications Staff Responsibilities Staff Responsibilities Resources & Assets (supplies, staff) Resources & Assets (supplies, staff) Safety & Security of Residents Safety & Security of Residents Utilities Management (power, HVAC, fuel, water, etc.) Utilities Management (power, HVAC, fuel, water, etc.) Clinical & Support Services Clinical & Support Services If you can’t meet it – say it or fix it! If you can’t meet it – say it or fix it!

8. Communications and Incident Management

9. CommunicationsCommunications Ongoing communications to: Ongoing communications to: Staff Staff On-duty (briefing) and Off-duty (sit-stat) On-duty (briefing) and Off-duty (sit-stat) Phone Number to Call Into Phone Number to Call Into Website to View with Emergency Information Website to View with Emergency Information Patients/Residents and Families (staff families) Patients/Residents and Families (staff families) Preplanning Information Preplanning Information How do you Inform them of the Situation…and keep them informed How do you Inform them of the Situation…and keep them informed See Next Page See Next Page Message on website, e-mailed out, blast fax to media, paged to staff, on main facility phones (briefed internally for staff as well) Message on website, e-mailed out, blast fax to media, paged to staff, on main facility phones (briefed internally for staff as well)

11. CommunicationsCommunications FAILURE (immediately post-Katrina) FAILURE (immediately post-Katrina) 2005: Hurricane Rita (Texas/Louisiana) 2005: Hurricane Rita (Texas/Louisiana) Same Hospital as Listed on the previous slide Same Hospital as Listed on the previous slide Message from the Governor and the Mayor’s Office Message from the Governor and the Mayor’s Office “All residents of the City of Corpus Christi MUST evacuate immediately” – followed by the instructions, etc. “All residents of the City of Corpus Christi MUST evacuate immediately” – followed by the instructions, etc. Problem? Problem? Influenza Pandemic – Governor Declares State of Emergency: Social Distancing (i.e. stay at home) is the recommended approach How do you get staff to come to work? How do you get staff to come to work?

12. CommunicationsCommunications Ongoing communications to: Ongoing communications to: External Authorities External Authorities External Authorities External Authorities Fire, Police and Public Health; Local EOC; DPH; DEMHS Fire, Police and Public Health; Local EOC; DPH; DEMHS No set Frequency for Influenza Pandemic reporting – Emergency Line Created at Time of Emergency No set Frequency for Influenza Pandemic reporting – Emergency Line Created at Time of Emergency Regular Communications Failure – HAM/Amateur Radio Regular Communications Failure – HAM/Amateur Radio Incoming Communications may come in form of: Incoming Communications may come in form of: Blast Fax Blast Fax Direct Phone Call Direct Phone Call Health Alert Network (HAN) when updated Health Alert Network (HAN) when updated All Facilities Should Sign On – IMPORTANT All Facilities Should Sign On – IMPORTANT Rolling phone, fax, e-mail, pager, etc. Rolling phone, fax, e-mail, pager, etc. If you are unable to reach DPH or other State Agency: If you are unable to reach DPH or other State Agency: Use Ethical Judgment on actions Use Ethical Judgment on actions

14. CommunicationsCommunications Ongoing communications to: Ongoing communications to: Vendors Vendors 24/7 Phone Numbers 24/7 Phone Numbers If entering high-risk area (i.e. National Guard controlling access) If entering high-risk area (i.e. National Guard controlling access) Letter from Facility Letter from Facility Directions if Necessary Directions if Necessary Carry their Own Company Badges/ID Carry their Own Company Badges/ID Inform Local EOC of shipment Inform Local EOC of shipment Use Incident Command System to run this

16. Incident Command Organizing the Chaos! Manageable Span of Control: 3 – 7

17. Incident Command

20. CDC Checklists In the Incident Command System, what position would handle these roles? Home Health The Organization point person for external communications (e.g. hospitals, nursing homes, health departments, social services agencies) has been assigned. (Insert name, title and contact information) Nursing Home A plan for cohorting symptomatic residents or groups using one or more of the following: Confining symptomatic residents and their exposed roommates to their room Placing symptomatic residents together in one area of the facility, or Closing units where symptomatic and asymptomatic residents (staff who are assigned to work on affected units will not work on other units?

21. Incident Command Education Free On-line Boring – except to people like me ICS 100, 200, 700 IS-100.HC Introduction to the Incident Command System for Healthcare/Hospitals IS-200.HC Applying ICS to Healthcare Organizations IS-700 National Incident Management System (NIMS), An Introduction Yale: EM103 NIMS (meets 100, 700) Yale: EM140 NIMS (meets 200, 700)

22. Communications Tool – Internal / From Field / To Corporate

26. Staffing Plan / Education

27. Staff Responsibilities Education, Education, Education: Education, Education, Education: What is expected of you? What is expected of you? Come to work in a disaster Come to work in a disaster Need to say this; don’t assume Need to say this; don’t assume What are their specific responsibilities? What are their specific responsibilities? Protect themselves (no exception – PPE use – for patient contact or non-patient contact), other staff, patients/residents Protect themselves (no exception – PPE use – for patient contact or non-patient contact), other staff, patients/residents Tasks will be outside of normal daily responsibility Tasks will be outside of normal daily responsibility Share through your association for all facilities to have consistent education

28. Staffing Plan How are they Called Back? How are they Called Back? Red / Yellow / Green OR On / Resting / Off Red / Yellow / Green OR On / Resting / Off Impact of changing staff hours on their family/dependants? Impact of changing staff hours on their family/dependants? If Limited Transportation, what are the Preplanned Pick-up Locations? If Limited Transportation, what are the Preplanned Pick-up Locations? Must Have Facility IDs in the Event of Roadblocks Must Have Facility IDs in the Event of Roadblocks Facilities with Strike Plans – Should already have Pick-up Locations Facilities with Strike Plans – Should already have Pick-up Locations Facilities with Severe Weather (ice / snow / flood) Plans – Should already have Pick-up Locations Facilities with Severe Weather (ice / snow / flood) Plans – Should already have Pick-up Locations Home Health – Any challenges? Home Health – Any challenges? Are there Plans for Housing Them Are there Plans for Housing Them Their Dependents? (elderly family, children, disabled) Their Dependents? (elderly family, children, disabled)

29. In Need of Staff Where can you get them from if in trouble? Where can you get them from if in trouble? Your Corporate Office – if applicable Your Corporate Office – if applicable Staffing Agencies – Draw from Outside State Staffing Agencies – Draw from Outside State Medical Reserve Corp (MRC) Medical Reserve Corp (MRC) Community Emergency Response Teams (CERT) Community Emergency Response Teams (CERT) Families (Staff and Patient/Resident) Families (Staff and Patient/Resident) Retired Staff (never burn bridges) Retired Staff (never burn bridges) Sister Facilities or Neighboring Facilities Sister Facilities or Neighboring Facilities

30. Staff & Family Education/Support Education: Staff/Patient/Resident Families Patient/Resident: Upon Admit or a New Client / Staff: Upon Hire Provide Info to Staff/Families/Responsible Party on Expectations in a Disaster and Support that May be Requested (ask the question) Home Health: Provide direct care for Priority 2 & 3 patients (phone support) Agency should increase verification process on accuracy of info – frequency determined by Agency Nursing Home: Family member may be requested to pick-up patient for discharge and care for them Family member may be asked to provide on-site volunteer support to care for residents (staff or resident families) Dialysis: Provide diet oversight for patient (phone support) Center should increase verification process on accuracy of info – frequency determined by Center

31. Staff & Staff Family Support Staff and Family Support Examples Staff and Family Support Examples Child care, elder care, communication, etc. Child care, elder care, communication, etc. CCRC – Better Ability to have Adult Day Care, Child Care (modifications), Lodging for Family CCRC – Better Ability to have Adult Day Care, Child Care (modifications), Lodging for Family Hotel, on premises, Sr. Independent Living or Assisted Living Residence, etc. Hotel, on premises, Sr. Independent Living or Assisted Living Residence, etc. Child Care Fears – Child Care Fears – Are these Real? Are these Real? How to Combat them? Or should you? How to Combat them? Or should you? Mental Health and Other Family/Staff Support Mental Health and Other Family/Staff Support CONSIDER THEM – These are not required, just need to be thought through and planned as to if you are or are not going to provide them CONSIDER THEM – These are not required, just need to be thought through and planned as to if you are or are not going to provide them

32. Family Disaster Planning Yale-New Haven Office of Emergency Preparedness Yale-New Haven Office of Emergency Preparedness Pamphlet Pamphlet http://yalenewhavenhealth.org/emergency/progsvcs/ commprep.html#personal http://yalenewhavenhealth.org/emergency/progsvcs/ commprep.html#personal http://yalenewhavenhealth.org/emergency/progsvcs/ commprep.html#personal http://yalenewhavenhealth.org/emergency/progsvcs/ commprep.html#personal Red Cross – Family Disaster Planning Guide Red Cross – Family Disaster Planning Guide http://www.redcross.org/services/disaster/0,1082,0_6 01_,00.html http://www.redcross.org/services/disaster/0,1082,0_6 01_,00.html http://www.redcross.org/services/disaster/0,1082,0_6 01_,00.html http://www.redcross.org/services/disaster/0,1082,0_6 01_,00.html Focal Areas Focal Areas Who has dependents (elderly, special needs/disability, child) Who has dependents (elderly, special needs/disability, child) Caring for them in a disaster? Caring for them in a disaster?

35. Supplies & Resources

36. Supplies/ResourcesSupplies/Resources Where can you get them from? Where can you get them from? Outside 90 mile agreements Outside 90 mile agreements Don’t do all the work, have someone do it for you (networking with other state associations to share supplier/vendor information) Don’t do all the work, have someone do it for you (networking with other state associations to share supplier/vendor information) Your Corporate Office – if applicable Your Corporate Office – if applicable Other State Facilities (if not directly impacted) Other State Facilities (if not directly impacted) Local Pharmacies Local Pharmacies Local Hospitals Local Hospitals Strategic National Stockpiles (SNS)/Push Packs Strategic National Stockpiles (SNS)/Push Packs *Rationing* *Rationing*

37. Stockpiling?Stockpiling? Financial Burden Financial Burden PPE PPE How much should you stockpile? How much should you stockpile? Calculate # of patients/residents Calculate # of patients/residents Calculate # of staff & # of shifts Calculate # of staff & # of shifts Delineate difference between clinical and non-clinical Delineate difference between clinical and non-clinical Review reuse strategies where safe to do so Review reuse strategies where safe to do so Home Health – Storage in cars with specific PPE that can be reused on the same patient Home Health – Storage in cars with specific PPE that can be reused on the same patient

38. ExampleExample Dialysis Center Dialysis Center 40 patients per day (110 total for the Center) 40 patients per day (110 total for the Center) 10 direct patient contact staff (3 nurses/6 techs, Dialysis Asst) 10 direct patient contact staff (3 nurses/6 techs, Dialysis Asst) 5 Admin/Support (Director, Social Worker, Receptionist, Dietician, Word Clerk) 5 Admin/Support (Director, Social Worker, Receptionist, Dietician, Word Clerk) Approx. 30 N-95 Respirators (x 2 for staff changes) / Glove Consumption Varies Based on Patient Contact (saturated N-95 could change life of respirator) Approx. 30 N-95 Respirators (x 2 for staff changes) / Glove Consumption Varies Based on Patient Contact (saturated N-95 could change life of respirator) Up to 8 Week Timeframe: Maximum of 1,200 N-95 Respirators for staff and potentially up to 1,600 respirators per patient (recommend patient reuse which could reduce this to minimal numbers over an 8 week period) Up to 8 Week Timeframe: Maximum of 1,200 N-95 Respirators for staff and potentially up to 1,600 respirators per patient (recommend patient reuse which could reduce this to minimal numbers over an 8 week period) REALITY: Reduction in Staff & Reduction in # of Patient REALITY: Reduction in Staff & Reduction in # of Patient 20 patients per day (110 still remains as #) 20 patients per day (110 still remains as #) 5 direct patient contact staff (2 nurses/3 techs) 5 direct patient contact staff (2 nurses/3 techs) 3 Admin/Support (Social Worker, Receptionist, Dietician) 3 Admin/Support (Social Worker, Receptionist, Dietician) Approx. 16 N-95 Respirators (x 2 for staff changes) and Glove Consumption Varies Based on Patient Contact (saturated N-95 could change life of respirator) Approx. 16 N-95 Respirators (x 2 for staff changes) and Glove Consumption Varies Based on Patient Contact (saturated N-95 could change life of respirator) Up to 8 Week Timeframe: Maximum of 640 N-95 Respirators for staff and potentially a total of 110 respirators for the patients (recommend patient reuse) Up to 8 Week Timeframe: Maximum of 640 N-95 Respirators for staff and potentially a total of 110 respirators for the patients (recommend patient reuse) Estimated Costs: $11 per box with 20 per box; 38 boxes at $11 = $418.00 Estimated Costs: $11 per box with 20 per box; 38 boxes at $11 = $418.00

39. Stockpiling?Stockpiling? Food – MREs, non-perishables (sample multi-day menus and feeding calculation document provided) Food – MREs, non-perishables (sample multi-day menus and feeding calculation document provided) Rationing due to staffing or supply availability could be necessary Rationing due to staffing or supply availability could be necessary Medications Medications Home Health – Eliminate vitamins and other baseline meds as necessary Home Health – Eliminate vitamins and other baseline meds as necessary Nursing Home – Elimination of non-essential meds via an Influenza Pandemic Med List Nursing Home – Elimination of non-essential meds via an Influenza Pandemic Med List Will you work to access vaccines and antiviral meds? Will you work to access vaccines and antiviral meds? Work with Corporate, State DPH, Associations, Local Public Health and Other Providers to address this during the disaster Work with Corporate, State DPH, Associations, Local Public Health and Other Providers to address this during the disaster Supplies (dialysers, lines, meds, saline, chemicals) Supplies (dialysers, lines, meds, saline, chemicals)

41. Emergency Resources & Contacts Emergency Agency Phone #’s (shown in communications) Emergency Agency Phone #’s (shown in communications) Emergency Alert System Emergency Alert System Emergency Bedding / Housing Plan Emergency Bedding / Housing Plan Emergency Staffing Agency Phone Numbers by Specialty Emergency Staffing Agency Phone Numbers by Specialty Materials Management / Nutrition / Pharmacy Departments Materials Management / Nutrition / Pharmacy Departments Emergency Contractors/Vendor Phone Numbers Emergency Contractors/Vendor Phone Numbers Emergency Supply / Food / Liquid / Meds Sources / Linens Emergency Supply / Food / Liquid / Meds Sources / Linens Mutual Aid Mutual Aid Stop-Over Site Agreements (Quarantine???) Stop-Over Site Agreements (Quarantine???) Nursing Nursing Emergency Contractors/Vendor Phone Numbers Emergency Contractors/Vendor Phone Numbers Transportation Resources Internal/External Transportation Resources Internal/External Utility Systems Utility Systems Emergency Contractors/Vendor Phone Numbers Emergency Contractors/Vendor Phone Numbers

44. TransportationTransportation

45. TransportationTransportation Utilization of Staff Vehicles for Supply Movement – Who has 4-wheel drive or pick-up trucks to move supplies? Utilization of Staff Vehicles for Supply Movement – Who has 4-wheel drive or pick-up trucks to move supplies? Patient location analysis to eliminate transportation redundancies: Patient location analysis to eliminate transportation redundancies: Dialysis Patients: Centralized management of transportation (pick-up other facilities patients: Private Transport Companies) Dialysis Patients: Centralized management of transportation (pick-up other facilities patients: Private Transport Companies) Pick-up Staff with the patients Pick-up Staff with the patients Leverage Facility Owned Vehicles (typically in Long- term care) Leverage Facility Owned Vehicles (typically in Long- term care) Why can’t a Nursing Home provide transportation to a Dialysis Center? Why can’t a Nursing Home provide transportation to a Dialysis Center?

46. TransportationTransportation Home Health Home Health Centralized pick-up points for essential administrative and support staff Centralized pick-up points for essential administrative and support staff Knowledge that gas supply chains could be disrupted Knowledge that gas supply chains could be disrupted Patient location analysis to streamline travel times Patient location analysis to streamline travel times i.e. elimination of visits to geographically dispersed patients i.e. elimination of visits to geographically dispersed patients Nursing Homes Nursing Homes If you do not have, secure a facility shuttle for staff pick- up points – preplanned arrangement If you do not have, secure a facility shuttle for staff pick- up points – preplanned arrangement If you do have, consider working in Mutual Aid Agreements with other providers to support transportation needs If you do have, consider working in Mutual Aid Agreements with other providers to support transportation needs

47. Utilities / Facilities

48. System Failures Potential that repair teams will be rendered incapable of supporting facility Potential that repair teams will be rendered incapable of supporting facility Know what can shut down your operations Know what can shut down your operations Dialysis Patients: If Reverse Osmosis water is disabled – can you use tap water? Dialysis Patients: If Reverse Osmosis water is disabled – can you use tap water? Nursing Home: If Generator is down due to power loss and no extended fuel back-up, do you have other means of redundancy? Nursing Home: If Generator is down due to power loss and no extended fuel back-up, do you have other means of redundancy? All: If your IT system fails and there are no staff to repair it, All: If your IT system fails and there are no staff to repair it, How will you bill? How will you bill? How will you ensure appropriate clinical data? How will you ensure appropriate clinical data? How will you ensure appropriate family/responsible party info? How will you ensure appropriate family/responsible party info?

49. Clinical Services

50. What are the strategies for providing a maximally attainable, minimally acceptable level of care? What are the strategies for providing a maximally attainable, minimally acceptable level of care? Exercise Exercise Dialysis: Typically 3 nurses and 6 techs on a shift Dialysis: Typically 3 nurses and 6 techs on a shift Down to 2 nurses and 3 techs for 8 weeks Down to 2 nurses and 3 techs for 8 weeks Strategy? Strategy?

51. Building Lockdown/ Containment Strategy Pre-designate What Doors for Monitoring Pre-designate What Doors for Monitoring Stabbing in the Parking Lot Stabbing in the Parking Lot Threat to Resident or Staff Life Threat to Resident or Staff Life Labor Action / Strike Labor Action / Strike Loss of Emergency Power Loss of Emergency Power Civil Unrest Civil Unrest Pandemic Influenza Pandemic Influenza Fever Testing at Entrance (customize off of DPH Plan) Fever Testing at Entrance (customize off of DPH Plan)

52. What is Fever Testing Screening Process for Employees, Family/Responsible Parties and Patients/Residents Screening Process for Employees, Family/Responsible Parties and Patients/Residents Allow or Deny Access to the Facility Allow or Deny Access to the Facility >101°F: Immediate Denial >101°F: Immediate Denial <99°F: Access Granted <99°F: Access Granted >99°F and 99°F and < 101°F: Follow Series of Questions Determine appropriate infection control protocols for isolation of or potentially to deny access for patients with Influenza Pandemic Determine appropriate infection control protocols for isolation of or potentially to deny access for patients with Influenza Pandemic Policy/Procedure included on CD-Rom to customize your facility specific plan for Fever Testing Policy/Procedure included on CD-Rom to customize your facility specific plan for Fever Testing

53. Fill In the Plan – Position / Department / Facility

54. Department/Position -Specific Plans Each department or position within our organization should have the responsibility to review and update critical functions in order for us to continue operations in a disaster. The plans should be formatted in the following manner:

55. Current staffing #’s / positions by shift Current staffing #’s / positions by shift Overall functions of the position/department Overall functions of the position/department Bullet List the Functions (i.e. Dietary in Nursing Home) Bullet List the Functions (i.e. Dietary in Nursing Home) Food preparation Food preparation Gather menus from floors Gather menus from floors Prepare carts/trays (specific dietary needs) Prepare carts/trays (specific dietary needs) Prepare lines Prepare lines Deliver meals Deliver meals Staff kitchen, line and register Staff kitchen, line and register Clean carts, trays, utensils, dishes, pots, pans and equipment Clean carts, trays, utensils, dishes, pots, pans and equipment Restock food and supplies (liquid consumables, staples, meats, dairy, etc.) Restock food and supplies (liquid consumables, staples, meats, dairy, etc.) Storage for food and supplies Storage for food and supplies Reordering of food, liquids, equipment and supplies Reordering of food, liquids, equipment and supplies Department/Position -Specific Plans

56. Functions that must be maintained and that can be suspended in a disaster situation Functions that must be maintained and that can be suspended in a disaster situation Dietary (sample list) Dietary (sample list) Limit food prep to emerg. Menu Limit food prep to emerg. Menu Disposable products Disposable products Consider moving to 2 meals/day plus snacks based on patient or resident needs Consider moving to 2 meals/day plus snacks based on patient or resident needs Billing Billing Need to bill, but what is the frequency? Need to bill, but what is the frequency? Minimal Staffing Operations Minimal Staffing Operations Home Health: Nursing / Aides Home Health: Nursing / Aides Suspend Priority 3 Services; Limit Priority 2 Services; Manage Priority 1 Patients – Discontinue Hospice Care at Nursing Homes Suspend Priority 3 Services; Limit Priority 2 Services; Manage Priority 1 Patients – Discontinue Hospice Care at Nursing Homes Re-establish Geographic Borders to Maximize Capabilities (work on alternative plans for geographically dispersed patients) Re-establish Geographic Borders to Maximize Capabilities (work on alternative plans for geographically dispersed patients) Limit initial patient assessment for new patients (rapid assessment) Limit initial patient assessment for new patients (rapid assessment) Department/Position -Specific Plans

57. Minimal Staffing Operations Minimal Staffing Operations Nursing Home: Nursing / Pharmacy & Billing Nursing Home: Nursing / Pharmacy & Billing Higher Acuity vs. Lower Acuity Residents: Reprioritize Service Capabilities Higher Acuity vs. Lower Acuity Residents: Reprioritize Service Capabilities Utilize non-certified staff or resident/staff families to provide direct resident care support (CNA) Utilize non-certified staff or resident/staff families to provide direct resident care support (CNA) Eliminate non-essential meds for Residents based on acuity Eliminate non-essential meds for Residents based on acuity Billing 2 weeks late vs. getting meds to the floor Billing 2 weeks late vs. getting meds to the floor Dialysis Dialysis Extension of patients to spread out dialysis treatments Extension of patients to spread out dialysis treatments Work to streamline physician orders – Emergency Physician Order Form Work to streamline physician orders – Emergency Physician Order Form Streamline admissions paperwork Streamline admissions paperwork

58. Department/Position – Other ?’s Inability to provide services from the department/area (relocate in the building to consolidate staffing or relocate to another physical location) Inability to provide services from the department/area (relocate in the building to consolidate staffing or relocate to another physical location) Information Systems down-time operations (i.e.: coders would go to the books and manually code – do you have all the necessary books?) Information Systems down-time operations (i.e.: coders would go to the books and manually code – do you have all the necessary books?) Inability to secure transportation for patients (dialysis)? Inability to access your patients (home health)? Inability to secure transportation for patients (dialysis)? Inability to access your patients (home health)?

59. Leadership Considerations Priority of Services that MUST continue (cash flow / clinical needs) Priority of Services that MUST continue (cash flow / clinical needs) How to pay staff with no revenue coming in? How to pay staff with no revenue coming in? Skeleton Crew – Essential Staff (based on Dept. Specific Plans) Skeleton Crew – Essential Staff (based on Dept. Specific Plans) When to determine if operations must cease? When to determine if operations must cease? Insurance to support short term or long term business interruption Insurance to support short term or long term business interruption Key relationships (if 2 nd or 3 rd in command need to take over) Key relationships (if 2 nd or 3 rd in command need to take over) Fundraising Fundraising Political Figures Political Figures Financing Short-term Emergencies Financing Short-term Emergencies Banking Leaders Banking Leaders

60. Mutual Aid Plan (MAP)

61. MUTUAL AID EVACUATION & SUPPLY PLAN  Agreement among member facilities to provide assistance to each other at the time of a disaster Northeast Ice Storm 1998 Florida Hurricanes 2004 Plan as a group of providers, not as a stand alone facility or corporation

62. NEED SUPPLIES Coordination with the Mutual Aid Plan (MAP) Coordination with the Mutual Aid Plan (MAP) 1) Standard Vendors first 1) Standard Vendors first 2) Regional MAP Vendors second 2) Regional MAP Vendors second Continuous interaction with Local EOC for non-medical needs Continuous interaction with Local EOC for non-medical needs 3) Joint Region MAP Vendors 3) Joint Region MAP Vendors Interaction with State EOC for non-medical and medical needs Interaction with State EOC for non-medical and medical needs 4) State of Emergency Declaration 4) State of Emergency Declaration Other facilities in your Regional MAP State of Emergency Declaration Other facilities in your Regional MAP State of Emergency Declaration Other facilities in your Joint Region MAP Other facilities in your Joint Region MAP

63. SUPPLIES Request verbally; followed by written Request verbally; followed by written Vendor MOU Vendor MOU Transport – may be offered by Donor facility Transport – may be offered by Donor facility Pharmaceuticals – see next page Pharmaceuticals – see next page Summary of Equipment and Supplies – Aggregate of all facilities Summary of Equipment and Supplies – Aggregate of all facilities Facility Specific Info Facility Specific Info Plan will include: Plan will include: Specifics that facilities will provide Specifics that facilities will provide Medical Supply / Equipment Vendors Medical Supply / Equipment Vendors General Supply Vendors (cleaning, waste removal, mattresses, linens) General Supply Vendors (cleaning, waste removal, mattresses, linens) Personal Protective Equipment (PPE) Personal Protective Equipment (PPE) Pharmaceuticals Pharmaceuticals Portable HVAC Portable HVAC Generators and Fuel Generators and Fuel Food and Liquids Food and Liquids

66. Russell Phillips & Associates, LLC New York / Connecticut / California 860-793-8600 saronson@phillipsllc.com www.phillipsllc.com