Standards for private organizations

2020 Edition

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

The organization plans for and coordinates emergency response preparedness.
2020 Edition

Currently viewing: ADMINISTRATIVE AND SERVICE ENVIRONMENT (ASE)

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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 ASE 6 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the ASE 6 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the 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 ASE 6 Practice standards.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Emergency Response Plan
  • 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

 
Fundamental Practice

ASE 6.01

The organization develops an emergency response plan that outlines its response to medical emergencies, facility and security-related 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. plans for maintaining service continuity.
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: Plans for maintaining service continuity can include, but are not limited, to:
  1. options for relocating service recipients;
  2. identifying a temporary work site in the event of facility closure; and
  3. arrangements for the provision of necessary medications when applicable.
Individuals that may require a plan for providing medications in the event of an emergency include: individuals with psychiatric conditions, individuals taking opioid treatment medications, and older adults. Arrangements can include maintaining a list of service recipients likely to be effected 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

ASE 6.02

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. ensure authorized and properly trained staff are available to administer these treatments; and
  2. have procedures and appropriate training in place to get affected individuals to urgent care or an emergency department immediately following overdose treatment to preempt the reoccurrence or worsening of symptoms.
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

ASE 6.03

Personnel, and service recipients in residential or daytime group care settings, 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.
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

ASE 6.04

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 (ECE) and Out of School Time Services (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
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.
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.