2022 Edition

Administrative and Service Environment (CA-ASE) 6: Emergency Response Preparedness

The organization plans for and coordinates emergency response preparedness.

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VIEW THE STANDARDS

Purpose

The organization’s administrative and service environments are respectful, safe, and accessible and contribute to organizational effectiveness.
1
The organization's practices fully meet the standard as indicated by full implementation of the practices outlined in the CA-ASE 6 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the CA-ASE 6 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the CA-ASE 6 Practice standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the CA-ASE 6 Practice standards.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Emergency Response Plan including service continuity provisions
  • Emergency Response procedures
  • Table of contents of training curricula
  • Documentation of consultation with a health professional
  • Emergency contact information
  • Training curricula
  • Documentation tracking staff completion of training
  • Documentation tracking completion of training for persons served, as appropriate
  • Fire drill logs
  • Interviews may include:
    1. Program directors
    2. Relevant personnel
    3. Persons served
  • Observe facility
  • Review case records for individualized medication plans, as needed

 
Fundamental Practice

CA-ASE 6.01

The organization develops an emergency response plan that outlines its response to medical emergencies, facility and security-related emergencies, public health emergencies, and natural disasters, and addresses:
  1. coordination with appropriate authorities and emergency responders;
  2. communication with the governing body, personnel, service recipients and their families, and as appropriate, the public, and the media;
  3. evacuation procedures including accounting for the whereabouts of staff and service recipients and the evacuation of persons with mobility challenges and other special needs; and
  4. participation with community partners and stakeholders in community recovery efforts, as appropriate.
Related Standards:

Interpretation

It is critical that emergency response plans include arrangements for the provision of needed medications when applicable. Individuals that may require an individualized plan for providing medications in the event of an emergency include: individuals with psychiatric conditions, individuals taking opioid treatment medications, and older adults.
Examples: Emergency situations can include, but are not limited to, accidents, suicide, fire, medical emergencies, flooding, hostage situations, bomb threats, active shooter, unlawful intrusion, physical assault, and other life threatening situations.

Examples: The organization can help ensure preparedness to enact the emergency response plan by: 
  1. identifying the staff that will communicate with authorities and emergency responders at each program location; 
  2. testing the lines of communication to staff, board, clients and the public; 
  3. identifying staff who are responsible for individuals with mobility challenges and other special needs; 
  4. confirming availability of sufficient supplies at each site such as masks, gloves, hand-sanitizer, first aid kits or supplies, a first aid manual, cleaning supplies, disinfectant, toilet paper, food, maintenance supplies, batteries, etc.; 
  5. maintaining up-to-date emergency contact information for all staff and service recipients;  
  6. ensuring availability of medications for people in residential facilities;  
  7. maintaining a readily available emergency response plan and procedures at all program sites; 
  8. developing plans for programs and administrative offices to operate with increased staff absences due to illness; and
  9. developing plans for managing responsibilities performed by volunteers or contractors, in the event they are prohibited from entering the facility. 

Examples: To ensure uninterrupted services to vulnerable populations in the event of an evacuation, arrangements can include maintaining a list of service recipients likely to be affected and pre-arranging for services outside the area likely to be evacuated.
 
Examples: Response plans in the event of a suicide can include:
  1. procedures for managing information about the death;
  2. coordination of internal or external resources;
  3. supports for those affected by the death;
  4. commemoration of the deceased; and
  5. follow-up with anyone at elevated risk for suicide.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Plans or procedures related to one of the standard's elements could be more explicit or detailed, or have not been reviewed recently.
3
Practice requires significant improvement; e.g.,
  • Plans or procedures related to at least one of the standard's elements:
    • Are vague and/or confusing and as a result may pose a risk; or
    • Are outdated or have not been reviewed in more than two years; or
    • Do not designate responsibility for coordinating a response, or for taking actions identified as being critical; or
    • Are not readily available to staff who may need them immediately in the event of an emergency.
  • Emergency response plans or procedures are "one-size-fits-all" and are not appropriately tailored to:
    • The specific needs of different geographic locations or jurisdictions; or
    • The needs of different populations (e.g., foster children or the elderly) at different programs.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • One of the elements is not addressed at all.

 
Fundamental Practice

CA-ASE 6.02

The emergency response plan includes provisions for service continuity that ensures ongoing mission-critical functions in the event of a disruption of normal services, and: 
  1. identifies temporary administrative and service delivery sites in the event of facility closure; 
  2. addresses the temporary delegation of decision-making authority when normal channels have been disrupted;
  3. establishes alternative methods of communication with staff and stakeholders during periods of disruption; 
  4. ensures uninterrupted continuity of critical IT operations; and
  5. is reviewed, tested, and updated at least annually.
Related Standards:
Examples: Continuity Plans allow flexible and scalable responses to emergencies and other events that could disrupt operations. "Mission-critical functions" include core services and operational functions that are necessary to the continued operation of the organization.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Plans or procedures related to one of the standard's elements could be more explicit or detailed, or have not been reviewed recently.
3
Practices are basically sound but there is room for improvement; e.g.,
  • Plans or procedures related to at least one of the standard's elements: 
    • Are vague and/or confusing and as a result may pose a risk; or
    • Are outdated or have not been reviewed in more than two years; or
    • Do not designate responsibility for coordinating a response, or for taking actions identified as being critical; or
    • Are not readily available to staff who may need them immediately in the event of an emergency.
  • Emergency response plans or procedures are "one-size-fits-all" and are not appropriately tailored to: 
    • The specific needs of different geographic locations or jurisdictions; or
    • The needs of different populations (e.g., foster children or the elderly) at different programs.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • One of the elements is not addressed at all.

 
Fundamental Practice

CA-ASE 6.03

The organization is prepared to treat injuries and respond to medical emergencies by:
  1. maintaining a readily available communication device, poison control information, and first aid supplies and manuals at all program sites and during off-site activities when applicable;
  2. consulting with a health professional, as necessary, to develop procedures for such situations; and
  3. maintaining emergency contact information for personnel and service recipients.

Interpretation

 Organizations that maintain Naloxone or opioid antagonist kits to treat opioid overdose cases:

  1. maintain at least two unexpired doses in accessible locations; 
  2. store personal protective equipment (PPE) close to the kit to facilitate quick response; 
  3. ensure staff trained in SAMHSA-approved protocols and procedures for reversing opioid drug crisis are available to administer these treatments;
  4. have procedures and appropriate training in place to get affected individuals to medical care immediately following overdose treatment to preempt the reoccurrence or worsening of symptoms;
  5. have procedures for documenting each incident where opioid antagonists were administered; and  
  6. have systems for maintaining and restocking opioid overdose equipment and medication to ensure availability of unexpired medication in an emergency. 
Note: Please see the Case Record Checklist and Facility Observation Checklist for additional guidance on this standard.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • First aid supplies at one site were outdated.
3
Practice requires significant improvement, e.g., one or more of the following was not readily available at one of the organization's program sites:
  • A telephone or other communication device; or
  • Poison control information; or
  • First aid supplies and manuals.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • One of the elements is not addressed at all.

 
Fundamental Practice

CA-ASE 6.04

Personnel from all the organization’s programs and administrative offices, and persons served in residential or daytime group care settings when applicable, receive training on implementing the organization's emergency response plan that is tailored as appropriate to:

  1. the specific types of emergencies faced by the organization;
  2. the level of staff responsibility;
  3. the needs, age, and developmental level of service recipients;
  4. program type; and
  5. geographic location.
Related Standards:
Examples: It may be appropriate for some staff to receive “gatekeeper training” on how to recognize, interpret, and respond to signs of suicide risk, and/or Mental Health First Aid training for recognizing and responding to signs of a mental health crisis.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Training is inconsistent across program sites; or
  • The curriculum related to one of the elements is not fully developed or lacks depth; or
  • A few personnel or service recipients have not yet been trained.
3
Practices are basically sound but there is room for improvement; e.g.,
  • Training is inconsistent across program sites; or
  • The curriculum related to one of the elements is not fully developed or lacks depth; or
  • A few personnel or service recipients have not yet been trained.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • One of the elements is not addressed at all.

 
Fundamental Practice

CA-ASE 6.05

Fire drills are conducted according to legal requirements, and held at least:
  1. during periods of both activity and rest, as appropriate to the program or service;
  2. once a month for every shift in Early Childhood Education (CA-ECE) and Out of School Time Services (CA-OST) settings;
  3. once a quarter for every shift in residential or daytime group care settings; and/or
  4. annually for other services and at administrative offices.

Interpretation

Residential programs for adults living independently in apartments, single-room-occupancy, or other independent living arrangements are not expected to conduct fire drills during evening and/or overnight shifts where staff do not have a continuous presence onsite. Such programs must still conduct fire drills at each program site during business hours.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Fire drills are conducted in accord with required timeframes, but drills during rest periods could be done more often; or
  • Procedures are vague or need clarifying, e.g., do not specify fire drill frequency for some non-residential or day programs.
3
Practice requires significant improvement; e.g.,  
  • Quarterly fire drills are sometimes missed for some shifts, or are rarely conducted at night in residential facilities, or service recipients are not awakened during nighttime drills; or 
  • Fire drill logs are poorly maintained or missing in some programs or sites; or 
  • The organization has not recently reviewed current legal requirements; or 
  • Fire drills are not conducted at some administrative sites. 
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • The organization rarely conducts drills; or
  • The organization never conducts fire drills during rest periods or at night.