SNFs and Homeland Security. (View on Washington).

The Department of Homeland Security was launched with a great deal of fanfare this winter, and many are wondering how it will help their homes or businesses prepare for the terrorist incidents that Secretary Tom Ridge describes as "inevitable." If your home or business is a skilled nursing facility, the answer is: Your best path to security is through local agencies, using standard disaster-response techniques.

Interviews I conducted recently with officials of the new department disclosed that the federal government does have a good intuitive sense of the problems faced by long-term care facilities. Officials recognize that the heightened sense of confusion that many residents experience with disrupted routines can complicate attempts to evacuate a facility. They further acknowledge that the minimum necessities for both staff and residents are far greater than the flashlight, fresh water, battery-operated radio, and canned goods that suffice for "sheltering in place" in a single-family home.

Homeland Security officials also acknowledge that uncertainty exists about the implications of their complicated color-coded "alert status" warnings for nursing homes--or for any other type of residence. In fact, the "red" and "orange" alerts issued by Homeland Security are designed primarily to affect so-called "first responders" such as police, fire and rescue departments, and private security agencies. In a Level Red situation, for example, first responders should cancel extended out-of-area training that might prevent them from quickly responding to a terrorist incident. For the rest of us, the different colors translate into a vague suggestion that we adopt "heightened awareness."

Concrete recommendations for nursing homes, though, are lacking. One reason is that experts who have examined the potential impact of various terrorist scenarios find little difference in appropriate response from that to a conventional disaster. According to Tom Olshanski, an official with the U.S. Fire Administration branch of the Federal Emergency Management Agency (FEMA), which has been folded into the new department, "The fact that a fire or explosion was set on purpose or is a worse incident than average doesn't make it essentially different from other such disasters." Another FEMA official pointed out to me that even the attack on the World Trade Center has parallels with other incidents involving aircraft crashing into buildings, albeit accidentally, including high-rise apartment houses and, during the 1940s, New York's Empire State Building.

FEMA officials say that the best advice they can offer nursing homes is to think through the types of disasters that they might encounter and plan accordingly. They suggest that the planning process should begin by answering a series of basic questions:

* What should the staff do in response to a given type of emergency?

* Who should be called when a disaster occurs?

* Can any residents help with the response to the disaster? If so, which ones, and what can they do?

* If residents need to leave the facility, how can they be escorted out quickly and safely, and where should they go? Most importantly, how can responsible officials keep track of who has left the facility and who has not?

* If transportation in the area is disrupted, how can all of the residents' needs be addressed by staff on site? Following a locally severe earthquake in 1994, for example, the Jewish Home for the Aging in Los Angeles made provisions for staff to remain on site during the first few days of recovery.

* Are there people or facilities in the surrounding community who can be asked for help--perhaps a nearby church, school, or other facility that could be used temporarily to shelter residents who've been evacuated?

Officials emphasize that disaster response planning does not mean simply writing a multichapter document that ends up sitting on a bookshelf for "future reference." Administrators should make certain that everyone who has a potential role in disaster response is familiar with the plan and is aware of his or her responsibilities. True, this is difficult in a field experiencing such high staff turnover, but it is far superior to the panic and confusion that result when personnel are not briefed fully about appropriate response to a fire, explosion, toxic spill, or weather emergency.

Another key element of planning, FEMA officials say, is to assume that the facility could be cut off from outside help for up to 72 hours. This translates into three days without outside electric power, telephone service, water, gas, or deliveries from outside vendors. The plan needs to identify items that can be stored in advance, the essential equipment that will need to be powered by an emergency generator, and the steps that can minimize the risks to residents who, along with everyone else, are deprived of outside help.

FEMA officials say that nursing homes have an urgent need to work with all local hospitals, clinics, and emergency medical services to discuss how to handle acute care needs in the face of a catastrophe. Many communities have found it helpful to formalize such relationships in a Memorandum of Understanding (MOU) that says, essentially, "We'll back you up if you'll back us up." Local emergency facilities can be overrun quickly following a sudden fire or explosion with massive casualties, such as the recent tragic incident at a Rhode Island nightclub. A prearranged MOU might allow the nursing home to house burn victims for a few hours in the facility while emergency medical personnel from a nearby hospital perform triage; in exchange, the nursing home would ask the hospital to provide similar coverage if disaster made it necessary to evacuate the SNF.

Federal legislation provides the possibility of financial compensation for SNFs that must be repaired or evacuated following a federally declared disaster. Publicly owned and not-for-profit nursing homes may apply to FEMA for grants to cover the costs of transporting residents in an evacuation, as well as the overtime and extra-hire salaries required in staffing the evacuation; other funds for disaster response are available as low-interest loans.

In general, however, response to an emergency caused either by a terrorist act, an accident, or an "act of God" remains largely in the hands of the local community. FEMA's recommendations are no different from what any responsible community should be contemplating. "You never know where the next disaster is coming from or what it will be," says one official, "but the kind of basic planning that FEMA has supported for years can't hurt, and can most definitely help in a time of crisis."

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