Appendix 3

= Appendix 3 Hazard Vulnerability Analysis =
 * 1) 	In the State of Delaware’s Division of Public Health Hazard Vulnerability Analysis (HVA), planners generated four HVAs: a statewide HVA for Delaware and HVAs for Kent County, Sussex County, and New Castle County. Each report ranked the sixteen hazards that were reviewed by a planning priority score based on four factors: probability, severity, at-risk population, and planning. This appendix is a summary of the top five results produced in each HVA. The following hazards should be considered when developing and reviewing the emergency plans for Newark Manor Nursing Home.
 * 2) 	The top five public health planning priorities for the State of Delaware are as follows:
 * 3) 	Pandemic


 * 1) 	The increase in EMS transport, primary care office visits, and demand for hospital beds, outpatient services, and laboratory services resulted in a high-severity impact for a pandemic. Due to the high-severity impact and the probability that it may happen several times over a 100‐year life cycle, a pandemic becomes a top vulnerability.
 * 2) 	Tornado
 * 3) 	The human impact is the main reason that planning for a tornado is a top priority. The increase in mortality, EMS transport, emergency department visits, and trauma center injuries produced the third-highest severity score in the HVA. Along with this severity score, the community impact score was high due to a long‐term disruption of transportation and businesses. This data resulted in a tornado being the second-highest vulnerability for Delaware.
 * 4) 	Winter Storm
 * 5) 	Winter storms are a moderate planning priority due to high hazard‐related interruption probability, meaning the storm’s ability to affect daily resources including interruption of public health staff services, outpatient services, and ancillary services increases the severity score. The probability of a winter storm occurring in Delaware is high, thus increasing its vulnerability.
 * 6) 	Hazardous Materials Release
 * 7) 	A hazardous materials release is a priority for Delaware due to the extra planning needed for the at‐risk population. Also, the mortality and emergency department visit rate per 100,000 per day would be at least 150 times greater than the normal rate. The release would cause the displacement of some of the affected population.
 * 8) 	Radiation Dispersal Device (RDD)
 * 9) 	When reviewing the anticipated results of an RDD attack, it is clear that this hazard is a planning priority for Delaware, due to its impact on the interruption of business continuity and mass care. The hazard‐related interruption for the healthcare service impact would also create vulnerability because normal demand would not be met.
 * 10) 	The top five planning priorities for New Castle County are as follows:
 * 11) 	Pandemic
 * 12) A pandemic incident is the top planning priority for New Castle County, due to its impact on the healthcare services and its high probability. The demand for primary care doctors will increase, along with the need for hospital beds that are set up and staffed. This hazard is also ranked first due to its possible continual impact on DPH for more than 14 days. At‐risk populations will also need to be carefully considered in the planning process.
 * 13) 	Tornado
 * 14) 	A tornado was ranked second in the planning priority category due a high human impact. The number of fatalities, emergency room visits, and trauma center injuries will greatly increase after a tornado. Along with these factors, this hazard will have a large impact on the community and will cause interruptions within healthcare services.
 * 15) 	Hazardous Materials Release
 * 16) 	A hazardous materials release was scored third in planning priority due to a high human impact score. The scores for mortality and emergency department visits were at least 150 times greater than the baseline data. The community impact score was also higher in business continuity, population disruption, and environment impact. All three would be interrupted for at least 14 days, resulting in an increased score.
 * 17) 	Radiation Dispersal Release
 * 18) 	When reviewing the results of an RDD incident, it is evident that this hazard is a planning priority for New Castle County due to its anticipated impact on the community, particularly in the areas of business continuity and population displacement. There was also a large mental health impact score, along with a high at‐risk population score.
 * 19) 	Biological Terrorism
 * 20) 	Biological terrorism is ranked fifth in planning priority due to an extremely high human impact score. The number of fatalities will be 139 times greater than the baseline data, along with a greater increase in the number of EMS transports and emergency department visits. Due to these high numbers, healthcare services and public health service will also be impacted.
 * 21) 	The top five planning priorities for Kent County are as follows:
 * 22) Tornado
 * 23) 	A tornado was ranked first in planning priority due a high human impact score. The increased number of fatalities, emergency room visits, and trauma center injuries would be substantial. Along with these factors, this hazard was shown to have a large impact on the community and would cause interruptions within healthcare services. Through these high scores and a high probability, this hazard was ranked first on the planning priority scale in Kent County.
 * 24) 	Pandemic
 * 25) 	A pandemic incident is a planning priority for Kent County due to its impact on the healthcare services and high probability score. The demand for primary care doctors will increase, along with the need for hospital beds that are set up and staffed. This hazard is ranked second due to its continuous impact on public health for more than 14 days. At‐risk populations will also need to be carefully considered in the planning process.
 * 26) 	Winter Storm
 * 27) 	The winter storm hazard is a planning priority for Kent County due to the interruption of healthcare services. Staffing will be a major issue, since many personnel will be unable to travel to work. This is also reflected in the business continuity and transportation scores. The number of persons in need of mass care also created a need for increased planning.
 * 28) 	Coastal Storm
 * 29) 	The coastal storm hazard is ranked fourth as a planning priority for Kent County due to its high probability of occurring. The high hazard‐related interruption of daily services in all impact categories increased the need for planning. At‐risk populations will also need extra considerations during this hazard. Mass care and population displacement are major factors following coastal storms.
 * 30) 	Hazardous Material Release
 * 31) 	A hazardous material release scored fifth in planning priority due to a high human impact score. The mortality and emergency department visit scores were at least 140 times greater than normal. The community impact was also high in the areas of business continuity, population disruption, and environmental impact.
 * 32) 	The Top five planning Priorities for Sussex County are as follows:
 * 33) 	Tornado
 * 34) Tornado was ranked first in the planning priority category due to a high human impact score. The number of fatalities, emergency room visits, and trauma center injuries would greatly increase because of this hazard. Along with these factors, this hazard will have a large impact on the community and will cause a tremendous increase in interruptions within healthcare services.
 * 35) Pandemic
 * 36) 	A pandemic incident was ranked second due to its impact on the healthcare services and its high probability score. The demand for primary care physicians will increase, along with the need for hospital beds that are set up and staffed. This hazard is also ranked second due to its continuous impact on DPH for more than 14 days. At‐risk populations will also need to be carefully considered in the planning process.
 * 37) 	Hazardous Material Release
 * 38) Hazardous material release was scored third in planning priority due to a high human impact score. The scores for mortality and emergency department visits were at least 120 times greater than the baseline data. The community impact score was also high in business continuity, population disruption, and environmental impact.
 * 39) 	Radiation Dispersal Device
 * 40) 	When reviewing the potential results of an RDD incident, it was concluded that this hazard is a planning priority for Sussex County due to its impact on the community, especially regarding business continuity and population displacement. Healthcare services will also see a large increase in demand, with an increased need for staffing, primary care doctors, and hospital beds.
 * 41) 	Biological Terrorism
 * 42) Biological terrorism is ranked fifth in planning priority due to an extremely high human impact score. The number of fatalities will be 298 times greater than normal, along with a greater increase in the number of EMS transports and emergency department visits. Due to these high numbers, healthcare services and public health services will also be impacted.

2.0	Facility-Specific Hazards

2.1	Following the building assessment of Newark Manor Nursing Home on 2/1/2013 the following addition hazards should be taken into consideration when developing and reviewing its emergency plans.

2.1.1	Mature Trees in the presence of strong winds may pose a danger from falling branches.

2.2	When examining the local floodplain maps (Attachment 1) of Newark where Newark Manor Nursing Home is located, the following areas should be taken into consideration based on the data and extra planning that may be needed.

2.2.1	Facility is not located in a FEMA identified flood plane

2.3	The location of Newark Manor Nursing Home may require extra planning measures based on local points of interest in the surrounding regions. Theses points of interest many result in an increased risk to specific hazards. The following is a list of points of interest that should be considered when developing and reviewing emergency plans.

2.3.1	University of Delaware

3.0	Facility Resident Care Services

3.1	Internal resident population characteristics and related programs also have the ability to increase vulnerability to specific hazards. The following clinical conditions will require extra planning for Newark Manor Nursing Home.

3.1.1	Dialysis Management

A.	This population includes residents with end stage renal disease.

B.	Newark Manor Nursing Home does not have residents who receive dialysis treatment.

C.	Extra vulnerabilities for this population include power outages, transportation delays, and closure of the dialysis site.

D.	Newark Manor Nursing Home has identified Christiana Care as their alternate treatment center sites and TransCare Ambulance or Logistic Care as their transportation venues.

E.	Residents have 30 day medication on hand. Brockie Pharmacy delivers each day. Emergency supply of medication help on hold at all times.

F.	Newark Manor Nursing Home will expand the emergency medication kit so that it is adequate to address elevated potassium levels

3.1.2	Respiratory Management

A.	This population includes but is not limited to residents with respiratory conditions such as Chronic Obstructive Pulmonary Disease (COPD), chronic and acute Congestive Heart Failure (CHF), pneumonia, respiratory infections, asthma, and related disease state and problem conditions. This population is oxygen dependent or requires respiratory management.

B.	Emergency electricity is provided by our generator

C.	Extra vulnerabilities include dependence on electricity and the effect of smoke inhalation or impaired air quality that may occur because of an emergency or disaster incident.

D.	How the Newark Manor Nursing Home will sustain 7- to 30-day inventory of needed medical supplies – Newark Manor Nursing Home keeps 2 weeks of medical supplies on hand.

E.	How the Newark Manor Nursing Home will provide special transportation measures that include safety provisions for oxygen canisters – Contracts with TransCare and Logistic Care

3.1.3	Pain Management

A.	This population includes but is not limited to residents with musculoskeletal, orthopedic, and neurological conditions.

B.	Newark Manor Nursing Home does not have any residents receiving RTC. Identifying resident on Real-Time Control (RTC) dosing, hospice or palliative care programs, and need of specialty beds.

Hospice Contracts – Seasons Hospice, Vitas Hospice, Heartland Hospice, Delaware Hospice

C.	Extra vulnerabilities for this population occur during power outages because of the inability to sustain IV pumps, ultrasounds, hot packs, electric stimulation, and specialty beds. – None in Facility

D.	How the Newark Manor Nursing Home will sustain 7- to 30-day inventory of needed medical supplies – Two weeks of medical supplies on hand

3.1.4	Behavior Management

A.	This population includes but is not limited to residents with Alzheimer’s and related dementia, psychiatric or mood disorders, or pre-existing conditions such as COPD or cardiac conditions that could be exacerbated by stress and anxiety.

B.	Newark Manor Nursing Home is responsible for keeping residents safe who have behavioral issues.

C.	Extra vulnerabilities for this population include power outages because of their increased ability to accelerate behavioral manifestations or decline in mood state. Also, outages can affect the security system so that it does not work properly, leading to inability to stop escape.

D.	How the Newark Manor Nursing Home will ensure that staff is available for monitoring exist – Exit doors have manual locks, also staff will monitor exits.

E.	 How the Newark Manor Nursing Home will assign permanent staff, as available, for continuity of operations and identify residents’ preferences and routines – Staff scheduled around the clock. Nursing and Administration are required to be present during an emergency. Staff may only leave once relieved by replacement staff.

F.	How the Newark Manor Nursing Home will obtain extra medications to last 7 to 30 days – Newark Manor Nursing Home has a 30 day supply of medications with daily deliveries from Brockie.

G.	How the Newark Manor Nursing Home will coordinate diversion activities – The Activities director will decide how to carry out diversion activities.

3.1.5	Infection Control Management

A.	The affected population includes but is not limited to residents who are currently undergoing treatment for infection or those who develop acutely emerging infections. Vulnerabilities include those with communicable diseases such as clostridium difficulties, MRSA, and VRE as well as respiratory infection, conjunctivitis, and related conditions.

B.	Facility has backup electricity from the generator as well as a potable water supply, enough for each resident for three days.

C.	Extra vulnerabilities for this population will include power outages that will affect the water supply, waste disposal, and the ability to operate electrical equipment.

D.	How the Newark Manor Nursing Home will coordinate the use of an interim generator, medical supplies, monitoring ports, IV sites, and antibiotic therapy – Newark Manor Nursing Home has an emergency generator installed. The Facility has a two week emergency supply of medical supplies. The facility does not provide care relating to monitoring ports or IV care. The Facility’s DON monitors the antibiotic therapy.

E.	How the Newark Manor Nursing Home will coordinate isolation of infectious residents – Case by case, under the supervision of the DON, ADON and Infection Control Nurse.

F.	How the Newark Manor Nursing Home will coordinate waste management and biohazard disposal – Maintenance will assist DON in waste management. Stericycle contracts with the facility for biohazard disposal.

G.	How the Newark Manor Nursing Home will coordinate extra medications to last for 7 to 10 days – Newark Manor Nursing Home has a contract with Brockie Pharmacy to deliver needed medications in an emergency.

3.1.6	Hospice and End-of-Life Care Management

A.	This population includes but is not limited to residents with an end-stage condition, those who have six months or less of life expectation, or those who receive hospice care. Conditions vary and symptom management is dependent on the underlying conditions and co-morbidities.

B.	Newark Manor Nursing Home has a portion of its population on Hospice care. These people will be cared for by in-house staff in the absence of a hospice worker.

C.	Extra vulnerabilities for this population include power outages due to the impact on the ability to provide respiratory support, pain management, nutritional support, and surface support.

D.	How the Newark Manor Nursing Home will coordinate extra medications and equipment needed for its population – Brockie Pharmacy will deliver medications.

E.	How the Newark Manor Nursing Home will ensure updated and reviewed fact sheets, advance directives/Do Not Resuscitate Orders (DNROs), and designated decision-maker information and contact numbers for all residents in a readily available format – Face sheets are updated in several key locations as information changes.

3.1.7	Falls Management

A.	This population is diverse and includes many residents with complex conditions.

B.	Newark Manor Nursing Home has ambulatory residents who will not be restrained without following proper procedures.

C.	Extra vulnerabilities include power outages, call light failures, environmental and situational hazards, changes, and alterations in care systems and routines due to the loss of adequate lighting, failure of call systems, relocation, or new living quarters.

D.	How the Newark Manor Nursing Home will provide consistency in routine and caregiver services if possible – Staffing levels will be set to usual standards for routine care. In an emergency, additional support staff may be required to help manage issues due to the emergency.

E.	How the Newark Manor Nursing Home will involve residents in diversion activities – Activities staff will plan for activities that keep the residents occupied as much as needed.

F.	How the Newark Manor Nursing Home will provide enhanced monitoring, especially with disruption of call systems – Staff will monitor hallways and rooms and regularly check rooms.

3.1.8	Nutritional Management

A.	This is a need that addresses the entire resident population. Various diseases and conditions can influence vulnerability and create a need for increased nutritional requirements and monitoring for signs of dehydration.

B.	Newark Manor Nursing Home maintains required food and water in case of an emergency. The kitchen will be able to prepare food as usual as the generator powers the kitchen.

C.	Extra vulnerabilities due to power failure lead to effects on enteral or parentaleral feeding, IV therapy, dialysis and those with potential for unstable blood sugars, often triggered by stress; acutely emerging conditions may warrant enhanced IV support with increasing risk for dehydration and related conditions. – No IV therapy or dialysis residents at Newark Manor Nursing Home

D.	How Newark Manor Nursing Home will update and review the list of residents on special diets, supplements, and those at risk for weight loss or dehydration – This procedure will continue as usual.

E.	How Newark Manor Nursing Home will closely monitor residents for signs of dehydration – Fluids will be given on regular basis, body temperature will be taken, urine will be monitored.

3.1.9	Wound Care Management/Prevention

A.	All residents are considered at risk for skin breakdown. There are a variety of diagnoses, treatments, and conditions that can present complications.

B.	Residents with wounds will be treated as usual. Extra care must be given during a disaster to discover and treat wounds.

C.	Extra vulnerabilities to power outages and evacuation must be considered.

D.	This population includes but is not limited to residents who will need to obtain specialty beds, extra treatments, or special transportation.

E.	How the Newark Manor Nursing Home will assess residents for potential skin breakdown – Regular body checks and skin assessments.

3.1.10	Disaster and Mental Impairment

A.	This population includes but is not limited to residents with dementia and delirium. The chaos and the changes in routine that are imposed by emergency situations can overwhelm even normally health and high-functioning residents, rendering them mentally unstable until the event is over. Individuals with dementia can experience worsening behavior. Professional caregivers (Certified Nursing Assistants [CNAs]) know the residents best and will have to utilize professional judgment when dealing with potentially frightened or volatile residents.

B.	Dementia training and supervision by nursing and administration. The staff knows the residents very well in this facility as our population changes seldom.

C.	How the Newark Manor Nursing Home will ensure that special judgments are made and extra care is given – audits by DON and ADON

D.	How the Newark Manor Nursing Home will ensure that residents who are cognitively impaired are never left unattended – Observation by nursing, DON and ADON.

E.	How the Newark Manor Nursing Home will provide up-to-date pictures in their files and identification information – Photos will be taken regularly to be attached to the face sheets.

F.	How the Newark Manor Nursing Home will ensure that corporate offices have up-to-date information and pictures if a resident does become lost – Face sheets are shared with corporate.