UTMB Health Emergency Plan 2020

INSTITUTIONAL EMERGENCY OPERATIONS PLAN

Table of Contents

Contents I. Overview ................................................................................................................................. 4 1.

2.

3.

4.

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Document Purpose ........................................................................................................ 4 Scope ............................................................................................................................ 4 Audience........................................................................................................................ 5 Emergency Preparedness Policy ................................................................................... 5 Goals and Objectives ..................................................................................................... 6

II. Mitigation ................................................................................................................................ 7 1.

2.

3.

4.

Hazard Vulnerability Analysis (EM.01.01.01 EOP2) ....................................................... 7 Risk and Vulnerability Assessment ................................................................................ 7 Building Elevations for Critical Operations ..................................................................... 9 Weapons of Mass Destruction ....................................................................................... 9

III. Preparation .......................................................................................................................... 10 1.

2.

3.

4.

5.

Annual Update of Plans, ...............................................................................................10 Staff Education (EM.02.02.07 EOP7) ............................................................................10 New Employee Orientation (EM.02.02.07 EOP7) ..........................................................11 Operating Units/Departments (EM.02.02.07 EOP7) ......................................................11 Essential and Non-Essential Personnel, Process for Classification and Definitions: (EM.02.02.07 EOP 2) ....................................................................................................13 6. Essential Personnel Credentials (EM.02.02.07 EOP9)..................................................14 7. Fitness for Duty.............................................................................................................15 8. Mutual Aid Agreements and Accommodations ..............................................................15 9. Disaster Response Contractors and University of Texas System Inter-Campus Services Plan ...............................................................................................................................15 10. Emergency Management Officials ..............................................................................16 11. Incident Management Training: NIMS Compliance (EM.01.01.01 EOP 7) ...................18 12. Emergency Communication ........................................................................................18 13. External Emergency Communications Center .............................................................18 14. Regional Hospital Disaster Planning (EM.02.02.03 EOP 4, 5).....................................19 15. Emergency Weather Preparations ..............................................................................19 16. Internal Emergency Plan .............................................................................................20 17. Fire Plan ......................................................................................................................21 18. Security (EM.02.02.05) ................................................................................................21 19. Utilities (EM.02.02.09) ..................................................................................................22 IV. Response ............................................................................................................................ 23 1.

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Implementation .............................................................................................................23 Chain of Command .......................................................................................................23 Emergency Response – Mass Casualty Incidents (EM.02.02.11 EOP2) .......................24 Mass Casualty Mortuary Needs (EM.02.02.11 EOP 7) .................................................26 Evacuation Plan and Alternative Department Locations ................................................26 Mandatory Evacuation – Tropical Weather ...................................................................26

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7. Hospitals Appropriate for Patient Transfers in Mandatory Evacuation ...........................27 8. Incident Command System (EM.02.02.07 EOP 2) ........................................................27 9. Local Emergency Management Coordination................................................................29 10. Regional Hospitals (Galveston County).......................................................................30 11. Regional Hospitals ......................................................................................................30 12. External Communication .............................................................................................31 13. Public Information Officer and News Releases ...........................................................32 14. Radio Stations ............................................................................................................32 15. Internal Communication System Failure......................................................................32 16. Activation of Weather Plans - Executive Decision .......................................................32 17. Evacuation of Visitors .................................................................................................34 18. Academic Weather Plan..............................................................................................34 19. Research Weather Plan ..............................................................................................34 20. Business Departments / Non-Academic, Non-Clinical Areas .......................................35 21. Personnel Accommodations (EM.02.02.07 EOP5) ......................................................35 22. Parking for Essential Personnel (EM.02.02.07 EOP5) ................................................35 23. Accommodations for Dependent Family Members (EM.02.02.07 EOP 5, 6) ...............35 24. Not Allowed – Appliances, Pets (EOP.02.02.07 EOP5) ..............................................36 25. House Staff and Faculty Accommodations (EOP.02.02.07 EOP5) ..............................36 26. Bedding (EM.02.02.07 EOP5) .....................................................................................36 27. Scrubs (EM.02.02.07 EOP5).......................................................................................36 28. Dietary Provisions (EM.02.02.07 EOP5) .....................................................................37 29. Ancillary Services (EM.02.02.07 EOP5) ......................................................................37 30. Hospital Personnel Availability (EM.02.02.07 EOP5) ..................................................37 31. Release of Personnel Before a Weather Emergency ..................................................38 32. Evacuation of University – Catastrophic Prediction .....................................................38 33. Disaster Privileges to Volunteer Licensed Independent Practitioners (EM.02.02.13 EOP1) ...........................................................................................................................38 34. Requesting an 1135 Waiver (EM 02 01 01 EOP 14) ....................................................38 35. Replenishment of Critical Supplies...............................................................................40 36. Tracking Staff During Emergencies ..............................................................................40 37. Emergency Provision of Critical Utilities (EM 02 02 09) ................................................40 V. Recovery (EM.02.01.01 EOP4)............................................................................................ 41 1.

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Damage Assessment and Repairs; Debris Removal .....................................................41 Volunteers ....................................................................................................................41 Emergency Recovery - Crisis Support Assistance (EM.02.02.07 EOP5).......................44 Post Event Procedures .................................................................................................45 Return to Regular Work Schedule (EM.02.01.01 EOP5) ...............................................45 Leave After the Emergency...........................................................................................45

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I. Overview 1. Document Purpose This document is the UTMB Institutional Emergency Operations Plan. As an institutional plan it applies to all UTMB facilities and campuses to include the Galveston Campus, League City Campus, Angleton Danbury Campus, Clear Lake Campus, all UTMB clinics, and any future site that UTMB might acquire.

Included in this document are policy, various plans, procedures, and authority for responding to emergency situations at UTMB. Each UTMB department, specialty care center, and clinic is expected to develop a plan specific to their operations. Areas to be included in these plans are discussed in the section titled Department Plans. Department plans shall complement the Institutional Emergency Operations Plan.

This plan has been developed over a number of years and it incorporates lessons learned from past emergency incidents. That said, the plan is not intended to restrict the actions of the UTMB President, Executive staff, or Incident Commander in responding to emergencies. UTMB uses an Integrated Emergency Preparedness Program. (Joint Commission Standard EM 04 01 01)

2. Scope The information in this document is institutional, and is applicable all campuses, hospitals, business and administrative offices, schools, institutes, and clinics, on Galveston Island and the mainland. The Institutional Safety and Security Executive Committee is responsible for the content of the document. The plan is reviewed annually, and approved by the Institutional Safety and Security Executive Committee and signed by the UTMB President. It is available on ISpace to all UTMB users with a valid network log-in and a copy is also available on the UTMB Website. The UTMB emergency preparedness program incorporates the four basic elements of emergency management: Mitigation, Preparation, Response, and Recovery. The Institutional Plan is organized by these major headings. Each element should be addressed in each departmental plan developed. UTMB uses an Integrated Emergency Preparedness Program (IEPP) as defined by UTMB. The IEPP covers all UTMB campuses and locations. Each UTMB hospital will participate in the development and maintenance of the UTMB Emergency Operations Plan. Risk assessment information specific to each campus will be included in the IEPP Communitybased risk assessment. Unique aspects of each hospital’s operations will also be integrated into the IEPP. The IEPP will maintain an integrated emergency communications plan that includes key emergency contact information relevant to each campus. (EM 04 01 01) Continuity Planning: (EM 02 01 01): UTMB maintains a continuity of operations 4|Page

plan that is incorporated as an annex to the Emergency Operations Plan. The UTMB Continuity of Operations Plan addresses both:  A high-level strategy to maintain the delivery of institutional missions, specifically including the delivery of healthcare services  Departmental Business Continuity Plans that support institutional missions Succession and Delegation of Authority: The UTMB President’s Office maintains the succession and delegation of authority plan.

Emergency Communications Planning (EM 02 02 01): UTMB’s Integrated Emergency Preparedness Program includes emergency communications planning. An Emergency Communications plan is incorporated into this Emergency Operations Plan. As an IEPP plan, the Communications plan incorporates contact information for all campuses. The Communications plan addresses contact information for staff, relevant agencies, and sources of assistance during emergencies. UTMB’s has a mass notification system based on Everbridge technology called UTMB Alerts. The main contact methods for other healthcare organizations is WebEOC, EMTrack, and EMResource.

3. Audience The information in this document is intended for all UTMB employees, students, contract employees, and volunteers. Information about emergency operations and employee responsibilities is included in UTMB new employee orientation, and should also be a part of each departmental orientation plan and new student orientation.

4. Emergency Preparedness Policy University of Texas System Policy 172 requires that all UT institutions develop an emergency management plan.

UTMB has formally adopted the National Incident Management System and has implemented the Hospital Incident Command System. This will integrate UTMB’s command structure into the command structure of local jurisdictions and the State of Texas (EM.01.01.01 EOP 7) Further, it is the policy of UTMB to provide a framework for response to emergencies, internal or external, naturally occurring or man-made, which will guide all staff in managing the event safely and assuring rapid recovery to normal operating conditions.

All UTMB employees, students, contract employees, and volunteers should have a working knowledge of the institutional emergency operations plan and the plan for their department or school. They will be expected to follow these plans in case of an emergency.

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UTMB will coordinate emergency preparedness and emergency response activities with local emergency managers and will provide medical expertise and support for governmental, business and other academic institutional emergency management efforts.

UTMB Institutional Preparedness will support each department and entity in the development, testing and implementation of their departmental emergency response plans.

In accordance with the standards of the Joint Commission, a minimum of two emergency preparedness exercises/drills will be conducted each year, separated by at least four months but not more than 8 months. Actual events that precipitate use of the emergency plan and are documented will be included in our presentation to Joint Commission as sufficient for this purpose. The President of UTMB is the final authority for approval of the Institutional Emergency Preparedness Plan.

UTMB leadership to include leadership of the medical staff is expected to participate in plan development, (EM.02.01.01 EOP1), as well as training and exercises.

UTMB will maintain a documented inventory of the resources and assets it has on site that may be needed during an emergency, including, but not limited to, personal protective equipment, water, fuel, and medical, surgical, and medication-related resources and assets. (EM.01.01.01 EOP 8) UTMB will use the Incident Command System and Hospital Incident Command System framework to manage all resources needed for the emergency to include medications, medical supplies, and non-medical supplies. (EM .02.02.03 EOP1, 2, 3)

5. Goals and Objectives The UTMB Emergency Operations Plan is designed to: A. Provide the logical and flexible chain of command to allow the maximum use of resources during an emergency/disaster.

B. Attend promptly and efficiently to all individuals requiring medical attention.

C. Minimize injury or illness to people, damage or loss of property, and damage or loss of records.

D. Provide maximum safety and protection for patients, visitors, employees, and students.

E. Safeguard UTMB’s facilities and data to enhance continued operations.

F. Respond appropriately and quickly, and when necessary, integrate UTMB’s Emergency Operations role with the emergency/mass 6|Page

casualty disaster plan of the surrounding communities.

G. Maintain and restore all normal services as quickly as possible following the emergency disaster.

H. Satisfy all applicable regulatory requirements.

I. Provide supportive action to the community and entire state in the event of an external emergency/disaster.

(EM.01.01.01; EM.02.01.01)

II. Mitigation 1. Hazard Vulnerability Analysis (EM.01.01.01 EOP2) The Environment of Care Committee shall conduct and record a Hazard Vulnerability Analysis (HVA) for the UTMB Health System at least annually. The Program Director for Institutional Preparedness will complete a HVA for the UTMB Campus at least annually. Facilities that are of sufficient distance from the main UTMB campus so that hazards may differ should conduct their own HVA – these facilities may be grouped together for the purpose of conducting the analysis if the hazards they face are substantially similar. Hazards specific to their location or staffing level must be addressed. Plans for responding to these risks must be developed and tested at least annually. Each department shall be responsible for identifying potential emergency situations and events and implementing procedures designed to minimize the impact on department operations.

Business Operations and Facilities (BOF) shall have responsibility for assessing building vulnerabilities campus-wide, and for addressing reduction of the threat.

BOF shall also be the group responsible for coordinating disaster response and recovery with respect to repairs and services or department relocations within UTMB facilities. BOF will assure each building or renovation project is in compliance with current basis for design specifications and the Hurricane Mitigation Study recommendations adopted in January, 2009.

2. Risk and Vulnerability Assessment At least annually, the Environment of Care Committee’s Emergency Management Subcommittee will complete a community-based risk assessment for UTMB. This assessment will be reviewed and approved by the Institutional Safety and Security Executive Committee. The Program Director for Institutional Preparedness will complete the community-based risk assessment in conjunction with campus officials and local agencies for each UTMB campus. Risk assessments for the UTMB clinic sites will be completed by Ambulatory Services / Clinic Managers with the support of the UTMB Program Director for Institutional Preparedness. Clinics may be grouped into geographic areas that share a similar 7|Page

risk environment for the sake of the risk assessment.

Vulnerabilities include but are not limited to: A. Natural events such as weather emergencies (including flooding, tropical storms, and hurricanes), B. Manmade events such as acts of terrorism and crime, C. Technology failures such as utilities interruption, (EM.02.02.09), and D. Conditions that affect staff availability to report to work (i.e., closure of causeway or ferry service.)

UTMB will share UTMB hazard identification and vulnerability information with the City of Galveston Emergency Management Officer and Galveston County Office of Emergency Management Coordinator to better integrate planning and response activities in our community. UTMB will participate in all city or county exercises designed to test our response to any emergency. (EM.01.01.01 EOP3, EOP 4) Risks identified will be the basis for assuring adequate and timely preparation, mitigation efforts and enhancements to recovery processes. (EM.01.01.01 EOP5) The identified vulnerabilities will also serve as the framework for constructing preparedness drills and exercises. This will include bioterrorism or infectious disease outbreak plans.

For campus wide emergency events or drills, department heads, supervisors, and administrators involved in emergency preparedness (i.e., actual emergency or an exercise/drill) will participate in a debriefing. An After-Action report will describe staff participation, the areas identified during the exercise that need improvement, as well as the corrective action recommended. The After-Action report will be prepared by the office of the Institutional Emergency Preparedness Officer (IEPO) or the Program Director for Institutional Preparedness  At least one annual drill will include a substantial number of simulated patients.  Fire drills in the patient care areas of the hospitals will be conducted quarterly during each shift.

All department heads, supervisors, and administrators involved in emergency operations (i.e., actual emergency or an exercise/drill) which require only a departmental response will prepare a debriefing (After Action) report. The report will describe staff participation, the areas identified during the exercise that need improvement, as well as the corrective action recommended. A copy of each report will be sent to the office of the IEPO and Program Director for Institutional Preparedness.

Any employee, student, contract employee, visitor or volunteer who observes an incident or condition which could result in an emergency/disaster must report this information immediately to the appropriate supervisor or to the University Police 8|Page

(ext. 21111). Fires should be reported directly to ext. 21211.

Department-specific emergency operations plans are maintained by the department. Department directors will review these plans with employees and volunteers at least annually to define specific roles or desired responses during an emergency.

3. Building Elevations for Critical Operations UTMB Business Operations and Facilities (BOF) has adopted a building elevation standard of 20 feet above mean sea level as “safe� for critical infrastructure on the main campus. New construction will be designed so that the elevation for critical infrastructure is at a minimum of 25 feet elevation.

Structures below this elevation are considered more vulnerable to flooding during periods of extreme water accumulation and/or storm surges. Building elevation standards for new or acquired campuses will be developed based on the risk of inundation.

BOF currently maintains a database that identifies the elevations of various buildings and the contents of their ground floor. These operations include automatic transfer switches needed to support back-up generators. (A mitigation plan is being implemented to move these facilities and functions to a higher elevation).

Each department on the ground floors of buildings shall develop a relocation plan, independently or as part of their business continuity plan, to allow uninterrupted operations during an event or immediately following any event that would make their current location unusable. BOF has evaluated the recommendations to relocate emergency power generators and transfer switches to locations above the 20 foot minimum elevation as renovations occur.

4. Weapons of Mass Destruction Biologic, Nuclear, Chemical and Explosive agents may be employed individually or in combination for terrorist purposes. UTMB Healthcare Epidemiology has developed a comprehensive plan (Bioterrorism and Emerging Infectious Diseases Readiness Plan) for the organizational response to mass exposure to biologic agents or individual exposures, which have potential for mass contamination of UTMB personnel or facilities.

UTMB facilities for decontamination of biologic and chemical exposures are located adjacent to the Emergency Department. Gross decontamination of any suspected exposure to biologic or chemical agents should be accomplished in the field by EMS or fire personnel, prior to transportation of the patient to UTMB. Secondary, comprehensive decontamination will be accomplished prior to admittance into the Emergency Department proper. (Note that the secondary decontamination conducted before entry into the cold zone (Emergency Room) is 9|Page

a more thorough and comprehensive decontamination than that conducted in the field) In the event of suspected contamination in the Emergency Department, UTMB Police will secure the building and no patient, visitor or staff traffic shall be permitted into the main hospital and clinic complex. Refer to the UTMB Bioterrorism and Emerging Infectious Disease Readiness Plan for further explanations of containment, isolation and quarantine, as well as recommendations for personal protective barriers and staff decontamination.

Employee response to other potential emergency conditions is found in the Emergency Procedures Manual. This guide should be in use in all departments, whether on campus or in remote locations.

III. Preparation 1. Annual Update of Plans, The EOP and the UTMB Preparedness Program will be reviewed and approved annually by the Institutional Safety and Security Executive Committee.

2. Staff Education (EM.02.02.07 EOP7) All staff will receive emergency training during the human resources ‘New Employee Orientation. At least annually each department, school and entity shall review its plan with employees and students; review staffing required for emergency operations and verify personnel information for each employee designated as Essential. The main method for this training is known as the Annual Acknowledgement process. By UTMB Policy, each UTMB staff member must meet with their manager (prior to June 1 of each year), and review their emergency roles and what is expected of them (and to whom to report in an emergency). Both the staff member and the manager must acknowledge this training session using Human Resources Annual Acknowledgement web application. UTMB also provides an annual all hazards emergency preparedness training. Staff may attend this training in person or view a video version on the UTMB website. Training addresses the Emergency Operations Plan; risk assessments, the Communications Plan, and relevant policies and procedures.

Each new employee shall be designated as Essential or Non-essential as part of their initial orientation, and shall demonstrate their knowledge and understanding of their duties and responsibilities as related to emergency operations.

Employees should recognize that Essential status might change from time to time, or as a function of the event (e.g. an employee in a basic science area specializing in bio toxins may be Non-essential for weather conditions, but may be re-designated as Essential in a suspected bioterrorism attack with an agent 10 | P a g e

with which the employee is familiar).

At least annually the Institutional Emergency Preparedness Officer (IEPO) will convene a meeting of all interested University staff for the purpose of (1) education on the basics of the plan (2) identification and discussion of any changes in the plan and (3) affording all present with an opportunity to ask questions about the plan. The IEPO and Program Director for Institutional Preparedness will invite internal and external experts to make presentations for the university community, which may include National Weather Services officials, City and County emergency management offices, UTMB logistics, Utilities, Maintenance, Police and others.

Members of the UTMB Incident Command are required to complete National Incident Management System, Incident Command System training per: http://www.fema.gov/emergency/nims/CurrentYearGuidance.shtm Employees will complete the on-line training and send a copy of their certificate to the Program Director of Institutional Preparedness. Front Line Staff (ER, Directors, Nurse Managers, COA’s, etc.) must take Incident Command System (ICS) 100 and 700 level training. Incident Command Staff are required to have NIMS 100, 200, 700 and 800.

3. New Employee Orientation (EM.02.02.07 EOP7) During institutional orientation, including new employee and new student orientation, the Office of Training and Development will present information on the Emergency Plan for each new employee, including the basic design of the Plan, expectations of each employee and their role(s) in disaster situations and an explanation of the system of Essential Personnel designations.

Complete written documentation for emergency management for The University of Texas Medical Branch at Galveston consists of two basic parts: (1) The Institutional Emergency Operations Plan, which governs the institution (UTMB) as a whole; and (2) the individual specialty health center, clinic, and departmental plans (policies, procedures, guidelines, and support documents), which detail specific responses to an emergency in accordance with the institutional plan.

All departments will maintain a copy of the Institutional Emergency Operations Plan and all support documents that relate to their department-specific emergency response and involvement.

4. Operating Units/Departments (EM.02.02.07 EOP7) A. The Institutional Safety and Security Executive Committee may designate that campus-specific plans be developed. Unit-level continuity plans must address general responsibilities of departments and their employees during an emergency/disaster, as well as unit-specific activities for protecting resources and equipment. Detailed unit-level plans are developed and maintained by each 11 | P a g e

unit. A UTMB Institutional Continuity Plan is in development and Unit-level continuity plans will be considered as appendices to this plan when it is completed.

Unit-level planning should address the question of identifying essential personnel in different emergency scenarios. For instance, those staff members that are non-essential in a major hurricane evacuation scenario may be essential in other disaster scenarios, or in emergencies that affect only part of the institution. Unitlevel Continuity Plans may address these points Unit-level plans should include, but are not limited to the following: 1. Hazard Vulnerability Analysis (only if the risk profile is different from the Institutional HVA) 2. Identification of key personnel and means by which to contact them 3. Whether the unit or component area (department) will be operational during an emergency (under various scenarios) 4. Evacuation plans 5. Shelter-in-Place plans (to include ongoing patient care) 6. Continuity of Patient Care, Academic, Research, or Support functions 7. Identification of Essential and Non-essential personnel job duties 8. Job-action sheets should be prepared and provided to all staff with emergency roles. The job-action sheets should describe in detail the tasks that they need to perform 9. Statement of Mission Critical Activities 10. An outline of the orderly shutdown of departmental processes 11. Identification of alternative sites for department functions 12. Identification of alternative locations for storage of supplies, records and other critical business items, if the primary department location must be vacated 13. Plans to address loss of workplace, loss of technology, and loss of workforce 14. Telecommuting plans if any 15. Emergency communications plans to include return to normal operations messaging 16. An outline of the process for restoring services following and emergency event B. The Institutional plan is intended to ensure that personnel in the institutional administration, academic administration, and business administration who are responsible for responding to emergency situations know specifically what functions they are to perform to accomplish the mission assigned to their departments. Unit-level or departmental plans should be patterned after the institutional plan, concisely stating the mission assigned, and defining the processes needed to accomplish the mission. Personnel of each entity should know: 12 | P a g e

1. Their emergency classification (Essential, Non-essential, etc.)

2. Who may authorize employee release from work, and means for employees to determine when to return to work 3. The location of the payroll policies that will apply during the emergency 4. To whom they report in an emergency and their emergency roles (for essential staff) To ensure the desired outcome during a real situation, departmental in-service education and practice drills should be sufficiently detailed and frequent enough to provide a thorough understanding of the plan as it applies to each employee.

Each manager should meet with each of their employees to complete the UTMB Annual Acknowledgement Form. This form documents whether an employee is considered essential or not. The employee attests that they have been instructed in their emergency role, and they know to whom to report in an emergency.

5. Essential and Non-Essential Personnel, Process for Classification and Definitions: (EM.02.02.07 EOP 2) Each Employee will, at the time of their initial employment, and annually thereafter, complete the UTMB Emergency Preparedness Employee Acknowledgement Form. Classification as Essential or Non-Essential will be made by Department management. The UTMB Incident Commander or Institutional Emergency Preparedness Officer reserves the right to modify the classification based on need. A change in any employee’s ability to serve as Essential must be reported to their department management and reassignment may be made.

A. Essential (E): Employees whose job function is essential to business, academic, research or clinical operations during times of a natural or man-made disaster. In each entity or department, leadership must assure there are sufficient numbers of personnel with requisite skills to accomplish departmental or other functions identified as critical to operations. Essential employees may be called upon to provide services under various circumstances including internal or external emergencies and may be assigned duties outside of their normal duties on the UTMB main campus or at remote locations. Staffing assignments will be made, to the extent possible, considering unique skills and individual employee needs. UTMB emergency management officials working with department management will define the number and type of material resources and personnel required to effectively prepare for, respond to and recovery from emergencies that confront the university.

Unit-level planning should address in detail the roles of essential employees in various scenarios. For instance, those employees that are non-essential in a major hurricane response may be essential in other disaster scenarios.

Employees designated as Essential may be assigned to: 13 | P a g e

1. Complete preparations in advance of a known emergency such as predicted flooding or a hurricane, prior to release from work duties; 2. Remain on site during an emergency event; 3. Accompany patients to evacuation destination hospitals and may be required to provide care at the destination hospital (s); 4. Relocate to remote locations to support non-patient care activities (business, academic, research or support services); 5. Provide medical services to displaced community residents; a. In shelters established on Galveston Island; or b. In shelters established at remote locations; 6. Follow local evacuation orders and depart from campus or their primary job function, but be available to return to work as soon as required by UTMB leadership (in advance of “all clear:) 7. Depart campus as part of a mandatory evacuation subject to return to work at the time an “all clear” notice is announced.

A roster of employees designated as Essential must be maintained by each department. At the time of Emergency Plan activation, these rosters may be requested by the IEPO. B. Non-Essential (N): Employees whose presence is not essential during a specific declared emergency status. Non-essential employees cannot leave until released by their supervisor and must return to work as usual under routine operations after emergency status has ended. Employees that are released must make every effort to receive updates from UTMB on the status of the institution so that they can return to work if the situation changes and UTMB returns to normal operations.

Unit-level planning should address in detail the roles of non-essential employees in various scenarios. For instance, those employees that are non-essential in a major hurricane response, may be essential in other scenarios where the emergency only affects part of the institution. Unit-level plans can address options to continue work if needed in alternate work locations or by telecommuting, in accordance with the unit’s business continuity plan. A telecommuting agreement may be necessary and should be coordinated with Human Resources.

6. Essential Personnel Credentials (EM.02.02.07 EOP9) Each Essential employee will be issued an Essential Personnel badge, to be attached to their UTMB Employee Identification Badge. This badge, together with the Employee ID must be presented for access to UTMB buildings during a disaster event, and will be required for personnel returning to work before the “all clear” notice is announced. Each Essential employee will also be furnished with a laminated card for their vehicles, which will allow entrance into a UTMB parking garage. Only one vehicle per employee will be allowed. For 2014, the Essential Personnel badge, UTMB ID card, and vehicle card are required to pass through 14 | P a g e

roadblocks controlling reentry to Galveston Island. Other control measures may be applied to specific emergencies. UTMB may need to modify the credentials used for priority access through road blocks based on guidance from local jurisdictions, and the Department of Public Safety. Members of the Incident Command will be provided with a vest (EM.02.02.07 EOP9)

7. Fitness for Duty Any employee designated Essential in our emergency response to any incident is expected to be fit to respond to the initial event and to remain fit for duty for the duration of the event. In those events which require staff to be housed in UTMB facilities (owned, leased or otherwise acquired properties) all university policies will be in effect unless expressly waived by the President, the IEPO or the Incident Commander. Each employee will be expected to rest during their offshift times but may be immediately recalled to duty if circumstances require.

Each employee must be alert, sober and competent to function.

8. Mutual Aid Agreements and Accommodations Mutual Aid Agreements have been executed between UTMB and various local agencies, which may provide shelter for personnel and vehicle parking during an emergency. A written acknowledgement of the agreement shall exist and the agency will indemnify and hold harmless UTMB for any physical or personal injuries that may occur while its personnel or equipment is on UTMB property.

While UTMB is not a shelter or evacuation destination, we do reserve the right to make our facilities available to local law enforcement, fire, emergency medical, public utility or military personnel, as well as employees of city, county or state agencies.

9. Disaster Response Contractors and University of Texas System InterCampus Services Plan UTMB and UT System have contracts in place with disaster response companies. These contractors are listed in the disaster mutual aid plan.

Contractors can supply emergency generators, chillers, water, fuel, and other necessities in preparation for or after a disaster. Additional state contracts exist with disaster response companies.

UTMB participates in the UT System Inter-Campus Services Agreement which specifies that each UT System campus will assist any other campus which requests resources that the affected campus cannot supply. Services and resources provided under this agreement can include (but is not limited to): A. Supplement personnel such as Police, Environmental Health, Safety or Physical Plant; B. Services such as remote work sites or remote information services hosting; 15 | P a g e

C. Equipment; D. Supplies; E. Housing for displaced students, faculty or employees; The UT System Inter-Campus Services Agreement specifies the mechanism to initiate a request for assistance and the appropriate person to initiate the response. The agreement also specifies the responsibilities for any UT Component employee or UT System employee who is a member of a Disaster Response Team (DRT) deployed to assist any component.

Members of any UT System – sponsored DRT will have previously completed a Volunteer Agreement (found in the Inter-Campus Services Agreement) and are credentialed for their specific skills. As such, UT Systems component employees deployed as DRT are not considered Volunteers as defined later in this plan.

DRT members must report to the UTMB Command Center for instructions and assignments.

UT System annually negotiates contracts for essential services necessary immediately following a disaster event. These services (water damage restoration, emergency power generators, and similar services) are available to each UT component under the agreement and can be requested as needed.

10. Emergency Management Officials The President designates the Institutional Emergency Preparedness Officer (IEPO). The IEPO together with the Program Director for Institutional Preparedness are responsible for the development, annual review, distribution, and control of the Institutional Emergency Operations Plan. Collectively, these officials constitute the UTMB Office of Emergency Management.

University of Texas System Policy 172 designates the institution President as being responsible to assure that an adequate emergency preparedness program is in place.

The President delegates authority to other institutional officials to assure that emergency response is effective. The delegation of authority is documented in the Institution Emergency Operations Plan.

Notice incidents (like hurricanes or planned events): The President is incident commander (or if not available the President will specifically designate another UTMB official for that role).

The Incident Commander (with advice from the Incident Command General Staff (Section Chiefs) and Command Staff makes major operational decisions such as:  Patient evacuation  Curtailment or shutdown of operations 16 | P a g e

 

Operational Objectives Major expenditure of resources

For no-notice incidents: (utility outages, fires, et c.): UTMB follows NIMS/ICS. The first person to be aware of an incident is the incident commander until relieved by a more experienced official. The on-scene incident commander seeks to resolve or contain the incident and communicates or escalates as needed. The BOF Executive On-Call and the Health System Administrator OnCall systems are aligned with this principle. For no-notice incidents the BOF Executive On-Call and Health System Administrator On-Call should be notified.

The On-Call officials may assume the role of IC at that time. On-call officials may:  Continue to resolve the incident with resources at hand; or,  Notify executives and activate the UTMB Command Center if needed  Recall UTMB staff as needed to staff the incident command or response effort If the incident is escalated to the institutional level the President will either be the Incident Commander or will designate one. If one is designated, that IC would keep the president informed and provide a detailed report of the incident in a timely way. If necessary, the president would ultimately assume the IC role.

The Health System Administrator On-Call, Clinical Operations Administrator, or the Director of the Pharmacy can direct that the Chempack (a supply of medications needed for an organophosphate incident that are staged at UTMB as part of the Strategic National Stockpile plan) be opened to treat patients if normal emergency supplies are insufficient due to the number of patients.

Other Campuses: The President may delegate authority to officials at other campuses (such as League City or Angleton Danbury) to address emergency no-notice incidents.

For example – For No-Notice incidents: a local campus Incident Commander (acting also in the role of campus Executive On-Call) would deal expeditiously with the incident; decide if escalation and executive notification were required immediately – or – make a timely report to the President and executive staff once the incident has been resolved.

For Notice Incidents like hurricanes where time and communications are available, the local campus Incident Commander would keep the Institutional Incident Commander apprised of the situation and the Institutional Incident Commander would make decisions with the advice of the local campus Incident Command and the UTMB Institutional Command Center staff.

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11. Incident Management Training: NIMS Compliance (EM.01.01.01 EOP 7) Individuals who occupy positions in the Emergency Operations Center will complete training in the National Incident Management System (NIMS) / Incident Command System (ICS), and / or the Hospital Incident Command System.

See http://www.fema.gov/emergency/nims/CurrentYearGuidance.shtm for the latest requirements for NIMS Compliance.

A record of incident management training for command center staff will be maintained by the Program Director for Institutional Preparedness; and on the UTMB Human Resources Training Management System. Candidates for the incident command will be notified by email so that they can complete assigned training. Incident Command System Standard Form 203 Organizational Assignment List or an equivalently formatted email will be used to inform Incident Command members on their specific assignment and to whom they should report for a specific incident. The notification may be made verbally if needed.

(EM.02.02.07 EOP 8)

12. Emergency Communication Trunked 800 MHz Radios and satellite phones are available for emergency communications.

The UTMB President generally delegates authority for emergency communications content to the Public Information Officer, but may reserve approval authority for release of messages on a case-by-case basis.

In the case of no-notice incidents where time is of the essence to make a warning to the UTMB Community (such as in an active shooter scenario), the President delegates authority to UT Police to make mass notification broadcasts.

In such cases, UT Police must report the circumstances of the notification to the UTMB President.

For unit-level planning, contact lists of staff and call trees should be developed in order to be able to contact needed staff in an emergency or to notify staff of changing conditions.

13. External Emergency Communications Center 800 MHz Radio base stations are located at UTMB Galveston Campus and at the League City Campus on the mainland.

The Internet application WebEOC is the primary method of communicating information contained in standard Incident Command Forms such as requests for resources to the State Operations Center / Disaster District Coordinator / and the 18 | P a g e

Catastrophic Medical Operations Center (CMOC) (located in north Houston). EM Resource is also used to convey information to the CMOC. Telephone, email, and 800 MHz radio and web applications are the primary methods to notify external authorities that emergency responses have been initiated (EM.02.02.01 EOP 3), and the methods of communicating with authorities during an emergency (EOP4).

The IEPO or Liaison Officer will maintain communications with the city and/or county emergency management center(s), the US Coast Guard or other governmental agencies via telephone and/or two-way radio.

14. Regional Hospital Disaster Planning (EM.02.02.03 EOP 4, 5) UTMB actively participates in all aspects of regional hospital disaster planning as defined or recommended by the Texas Department of State Health Services (DSHS) or other agencies, and will follow guidelines promulgated by the Regional Hospital Disaster Planning Committee. Hospitals and healthcare providers located in DSHS Trauma Services Region R (TSA-R), have agreed to work together to cooperatively manage events including bioterrorist attacks, mass casualty incidents or injuries resulting from natural disasters. Cooperation in these situations includes, but is not limited to: expedited patient relocation, supply, medication and equipment sharing, communications, and staff reallocation. TSA-R hospitals working together as a Regional Planning Committee are responsible for the plan details including plan activation and processes for resource sharing.

UTMB participates as a member of the Regional Advisory Committee and the Catastrophic Medical Operations Center (CMOC). In order to better serve the needs of the region the CMOC has designated a seat for a member of TSA-R. UTMB will identify several key employees who will rotate staffing the seat in the CMOC in the event the CMOC has been activated for an event affecting the region.

15. Emergency Weather Preparations With advice from the IEPO and/or the Director of Institutional Preparedness the Institutional Incident Command (President or designee) will direct that emergency weather preparations will begin in all UTMB departments. Hospital services will be curtailed in an orderly manner. Academic activities such as the suspension of classes will be evaluated and communicated to the campus based on the nature and severity of the weather event.

For severe weather events that might require an evacuation (such as a hurricane): A. Patients will be discharged when medically possible to return to their homes and/or to seek safety outside the affected area.

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B. Patients who cannot be discharged will be relocated to as few patient care areas as possible. This will allow UTMB and its hospitals to function with maximum efficiency but with minimum staffing.

C. Personnel essential to healthcare operations will be identified by department management, subject to approval by the IEPO and/or incident commander (if the EOC is activated ); D. In the event that a catastrophic hurricane is predicted for Galveston, and with the assistance of the Texas Division of Emergency Management, UTMB will evaluate feasibility of a total patient evacuation. If the decision to evacuate is made, the steps outlined in the Patient Evacuation Plan will be implemented.

UTMB schools will be closed at the direction of the Incident Commander, following consultation with the Provost and Deans (Academic Operations Section). The Incident Commander with the assistance of the Public Information Officer and the Academic Operations Section Chief will communicate the decision and time classes will be suspended to the Institutional Emergency Preparedness Officer (or Incident Commander), who will assure the message is announced via all communications systems available.

If the threat increases and services are curtailed, non-essential personnel will be released from duty and instructed to seek safety. If necessary, and if such action is authorized, preparation will begin for shut down of non-essential departments.

The Support Operations Section will maintain a workforce on site in case there is an emergency within the hospital during the storm. These personnel will also assess damage to structures immediately after the storm has passed, before non-essential personnel return. These personnel will advise the Incident Commander on structural integrity and safety issues for personnel to re-enter university buildings.

Buildings previously closed during an emergency will only be re-opened after a proper inspection which finds them safe for occupancy. Any building judged to be unsafe will continue to be closed. Affected departments are expected to implement Continuity Plans.

16. Internal Emergency Plan The Internal Emergency Plan is designed to ensure that all personnel are adequately trained and are capable of responding quickly and efficiently to situations, which directly endanger personnel, patients, or visitors, in their areas.

Responses to fires, power failures, bomb threats, potential release of hazardous agents, and threatening phone calls are specifically addressed.

UTMB staff should refer to the “Environment of Care - Emergency Procedures Manual� for On Campus Facilities or for Off Campus Clinics which 20 | P a g e

outlines procedures and precautions to follow for specific emergencies.

In the event that the EPIC system is unavailable, staff will initiate procedures as defined in the Business Continuity Plan (BCP). A down-time box should be available for all patient related areas, e.g., inpatient, clinic, lab, etc. Boxes may hold forms specific to the department/clinic, as well as common forms.

Departmental Business Continuity Coordinators should assist in initiation of BCP in their specific areas. (EM 02 02 11 EOP 8) In the event that any utilities are disrupted for an extended period of time, patient hygiene should be addressed through the use of alcohol hand rubs for hand sanitation, Comfort Bath for bath care, waterless shampoo and diaper wipes. Potable water should, also, be available through BOF for limited uses.

(EM 02 02 11 EOP 5)

17. Fire Plan UTMB follows a two-tiered approach to fire plans. Each department has their own written fire response specific to their area and local needs. Additionally, should a fire event be significant (e.g. requiring evacuation/re-location of inpatients etc.) then UTMB will activate the Incident Command System and work with local authorities to ensure safety of life and then of property. EHS assists departments in developing their specific fire response plan and provides a common framework of minimum expectations reflected in these plans. Minimum expected responses are dependent upon the occupancy of the building and may include either full evacuation or a defend-in-place strategy, as appropriate. Defend-in-place strategies are closely coordinated with local fire response agencies to ensure the safety of the patients, visitors and staff of each building. Proactive fire prevention is accomplished through adherence to the National Fire Protection Association (NFPA) fire safety codes as adopted by the Texas State Fire Marshal’s Office (TSFMO), response training of all employees, the execution of drills on a periodic basis and regular inspection of UTMB properties and fire safety equipment. EHS is responsible for conducting drills, performing equipment and property inspections as well as either correcting or communicating and tracking to correction any deficiencies discovered.

18. Security (EM.02.02.05) UTMB maintains its own Police Department, which is approved by the Texas Commission on Law Enforcement and accredited by the Commission on Accreditation for Law Enforcement Agencies. The UTMB Police Department will provide internal security during emergencies. UTMB Police and Emergency Management collaborate with local jurisdictions, and can request mutual assistance as required. As a state agency, UTMB can request state assets to 21 | P a g e

augment security if needed. If additional security agencies are requested, UTMB will establish a unified command to coordinate activities. UTMB collaborates in emergency planning with city, county, and state officials to include development of the regional re-entry plan. Essential UTMB employees with credentials will be allowed to pass through roadblocks. Escorts from the Department of Public Safety are available. UTMB Police Department will control access to UTMB facilities as needed. Essential personnel will need to display credentials for both their vehicle and person. Parking will be in designated lots / garages. For emergencies where patient care operations continue, UTMB Police Department will control access and direct traffic flow as needed. UTMB Police will be positioned at strategic locations within the facility to maintain security. Essential personnel are provided with credentials for their vehicle and will be allowed to park in designated lots / garages. UTMB will control patient vehicles as needed during the emergency. The Public Information Officer will provide public announcements providing information on vehicle access to the campus.

(UTMB offsite clinic locations and campuses may need to depend primarily on local law enforcement agencies)

19. Utilities (EM.02.02.09) The HVA lists utilities outages as a significant hazard. (When the Command Center is activated, BOF will fall under the Support Operations Section.)

Business Operations and Facilities (BOF) maintains contingency plans and standard operating procedures to address the alternative means of providing:  Electricity (backup generators, portable generators, fuel storage, fuel supply, disaster response contractors)  Water needed for consumption and essential care  Water needed for equipment and sanitary purposes  Fuel required for building operations or essential transport (fuel storage tanks, contingency contracts, disaster response contractors, contingency plans with the State Government for emergency transportation)  Medical gas and vacuum systems  Utility systems defined as essential to UTMB o Vertical and horizontal transport o Cooling and heating o Steam for sterilization For offsite clinic locations, BOF will assist clinic management in working with leasers and local utility companies to maintain and restore service.

In addition to the main campus BOF will support continuity of service for other UTMB campuses.

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IV. Response UTMB uses the Hospital Incident Command System (HICS) to manage incidents.

UTMB’s highest level of incident management is the UTMB Command Center. Based on the nature of the emergency, the UTMB Incident Commander may delegate authority for ‘Sub-Commands’ that would report up to the UTMB Command Center. Subcommands could be based geographically, or by UTMB organization (e.g. the Health System), or in any manner designated by the UTMB Incident Commander.

UTMB will maintain internal resources, and implement mechanism for external support so that it will be able to maintain communications, resources and assets, security and safety, staff, utilities, and patient care for at least 96 hours when support is not available from the local community. (EM.02.01.01 EOP3)

1. Implementation The President has designated the Institutional Emergency Preparedness Officer and activation of our plans will follow a chain of command outlined in a following section of this document. (EM.02.01.01 EOP5, EOP6) The UTMB community must understand that implementation of any phase of the institutional plan will be based on the best information available to the decision-makers. UTMB employees, students and staff should not make assumptions about the UTMB response based on external announcements. For example, declaration of a hurricane watch by the National Weather Service (NWS) does not automatically activate any part of this plan. While declaration of such a status by institutional administration is almost certain to follow such an announcement by the NWS, personnel and students should not begin implementing the Emergency Weather Plan prior to being officially notified of a UTMB administrative decision.

2. Chain of Command The President of UTMB is the authority for activation of the Institutional Emergency Operations Plan and Institutional Command Center. If not available the President may designate an official to take the role of Institutional Incident Commander. If not available to make a designation, the following officials have delegated authority from the President to activate the EOP and Institutional Command Center.

A. Institutional Executive Vice Presidents; Chief Academic Officer B. Institutional Emergency Preparedness Officer C. Ranking administrative official on site D. Director of Institutional Preparedness After hours, emergency plans may be activated by: A. Health System Administrator on Call B. Clinical Operations Administrator 23 | P a g e

C. Business and Finance Executive On-Call For League City Campus, Clear Lake Campus and Angleton Danbury Campus: When time for emergency response is of the essence, the following officials have delegated authority from the UTMB President to activate campus plans and incident command: A. Campus Administrator B. Campus Emergency Preparedness Officer C. Campus Health System Administrator On-Call D. Campus Facilities Representative On-Call For Facilities-related incidents, emergency plans may be activated by the Vice President for Business Operations and Facilities or his/her designee. In any case, the first UTMB staff member to become aware of an emergency incident, or the first to arrive at the scene of an emergency should report the emergency and if trained, establish an Incident Command to respond to the emergency in accordance with the National Incident Management System / Incident Command System. As soon as is practical, the incident should be reported to the officials listed above. (EM.02.01.01 EOP5, 6) For Police actions, the Chief of Police may activate a law enforcement incident command as needed and may delegate authority to police officers as needed.

3. Emergency Response – Mass Casualty Incidents (EM.02.02.11 EOP2) (Note: A separate Mass Casualty Incident Appendix has been developed and is listed in the Emergency Planning I-Space Folder).

For the UTMB Main Campus: The Emergency Department may establish an Incident Command Post within the Trauma Center to help organize the response to a mass casualty incident (MCI) The Emergency Department may establish an Incident Commander for the MCI. If necessary, the Emergency Department may request that the Institutional Command Center be activated in support of the MCI response.

Upon notification of a major external emergency with mass casualties or significant implications for UTMB, the Emergency Department will notify the appropriate personnel and as needed notify the CMOC, Galveston City and County emergency management officials, local EMS providers, other hospitals, or other governmental agencies as appropriate. EM System, EM Resource, or EM Track may be used to make the notifications at the discretion of the Emergency Department. Immediate notification to the leadership of vital departments will be made utilizing the emergency paging system, electronic mail, Internet and telephone (UTMB Alerts call lists may also be used).

The Emergency Department will request adequate nursing and support 24 | P a g e

personnel and supplies if casualties are expected.

The Emergency Department will activate its departmental emergency plans and identify any needed resources to the Health System Administrator On-Call. A Hospital Command Center may be activated and all requests for assistance (supplies, manpower etc.) will be channeled to the Hospital Command Center. In the event of an influx of patients from vulnerable populations i.e.: geriatric, pediatric, disabled or patients with chronic medical conditions, the Hospital Command Center will notify UTMB physicians specializing in these fields (Pediatrics, Geriatricians, Internal Medicine) to assist with the care of these patients. (02 02 11 EOP4) The Health System Administrator On-Call or Clinical Operations Administrator will ensure that support areas such as the Operating Room, Recovery Room, Intensive Care Units, Pharmacy, Central Supply, and Blood Bank are prepared to support these demands with additional supplies. Routine activities will be curtailed or altered as necessary to allow proper response to the emergency.

The Administrative Director of the Emergency Department will determine inpatient bed availability. If necessary, authority to initiate the discharge of certain patients will be given by the Chief Medical Officer or a designee.

Emergency Department personnel or staff in the Hospital Command Center if operational will update UTMB bed status in EM Resource or other electronic message boards to assure information on our capacity and capability is accessible by the regional medial operations centers, EMS providers and other hospitals statewide.

The Chief Academic Officer will advise the Health System Administrator On-Call on the most appropriate action to be taken with regard to faculty and students.

The Chief Academic Officer may consult with the Deans of the respective schools and the President, as necessary to determine the most appropriate response. The Health System Administrator On-Call (or Incident Commander) will assure the message is announced via all communications systems available.

The response to external emergencies is expected to be scalable and appropriate to the needs of patients, families and the community. Our response may include a limited activation of plans (such exclusively in the Emergency Department) or may require activation of the full institutional plan, and Incident Command System.

If UTMB plans to suspend major operations due to an infectious disease outbreak or other major incident, the UTMB President will confer with the UT Chancellor and Executive Vice Chancellor for Health Affairs.

In the event that UTMB cannot be supported by the community in the effort to 25 | P a g e

provide communications, resources and assets, security and safety, staff, utilities, or patient care, the UTMB Incident Commander has the option of requesting resources from e.g.:     

University of Texas Institutions through the UT Resource Guidebook UTMB Disaster Response Contractors The Texas Division of Emergency Management, Disaster District Committee Chair or Regional Liaison Officer The East Texas Gulf Coast Regional Trauma Advisory Council / Catastrophic Medical Operations Center Regional Hospitals to include the Texas Medical Center

(EM.02.01.01 EOP3)

4. Mass Casualty Mortuary Needs (EM.02.02.11 EOP 7) Attended or In-Hospital Deaths: In an event which includes casualties in numbers that overwhelm UTMB’s Department of Pathology Autopsy Service, UTMB will utilize the facilities of the Galveston County Medical Examiner (ME) for temporary holding of deceased patients. If the ME cannot accommodate UTMB needs, a refrigerated truck will be secured under the UT System Disaster Mutual Aid Agreement or from other state sources or disaster response contractors and located on the UTMB campus in a discrete, secure location.

Unattended or Dead-on-Arrival Deaths: The Galveston County Medical Examiner has primary responsibility for the investigation of all unattended deaths. In an event with multiple mass casualties who are dead on arrival at UTMB, the ME will be notified and will guide UTMB on the disposition of remains pending his inquest.

5. Evacuation Plan and Alternative Department Locations Horizontal and/or vertical evacuation of patients and staff required because of fire, utility failure, etc., in any UTMB facility shall follow posted evacuation plans in each unit or department. Patients in any affected building will be moved to an alternative patient care unit, staff, students or faculty in any research or academic building will relocate to a safe alternative location as directed by the IEPO or Medical Emergency Preparedness Officer. (EM.02.01.01 EOP 7)

6. Mandatory Evacuation – Tropical Weather If a mandatory evacuation is ordered by a city or county official, UTMB may implement the Hospital and Clinic Patient Evacuation Plan to relocate patients to safe facilities off Galveston Island at inland locations beyond the expected surge zone or hurricane landfall impact area – or the UTMB Command Center may decide to shelter-in-place. UTMB need not wait for a mandatory evacuation order to decide to evacuate patients. A copy of the Patient Evacuation Plan is appended at the end of this document. (EM.02.01.01 EOP7) 26 | P a g e

7. Hospitals Appropriate for Patient Transfers in Mandatory Evacuation The following are hospitals with capabilities and usually with capacity to receive evacuated inpatients from UTMB, and are located a sufficient distance from the Gulf of Mexico coast line to assure patient safety from tropical weather events that threaten Galveston. This is not an inclusive list, and the Catastrophic Medical Operations Center (CMOC) (Houston) or Regional Medical Operations Centers in Austin or San Antonio will also be resources for locating appropriate beds for patient transfers. (EM.02.01.01 EOP7) Seton Healthcare System Hospitals, Austin, TX (512) 324 1000 (Main), (512) 324 1951 (Administration) (Will identify specific hospitals at the time of transfer) St. David’s Healthcare System Hospitals, Austin, TX (512)544 4418 (Main) University of Texas Southwestern Medical Center, Dallas, TX (214) 645-5555 (Zale Lipshy) (214) 645-5555 (St. Paul) (214) 590-8000 (Parkland) (214) 456-7000 (Children’s) University Health System Hospitals, San Antonio, TX (210) 358-4000 (Will identify specific hospitals at the time of transfer) Methodist Hospital, San Antonio, TX (210) 575-4000 Cook Children’s Hospital, Fort Worth, TX (682) 885-4000

8. Incident Command System (EM.02.02.07 EOP 2) UTMB will employ the fundamentals of the National Incident Management System (NIMS) Incident Command System to manage emergency conditions in cooperation with external public service agencies. Members of the UTMB Incident Command must be trained. UTMB may use internally developed training materials to perform this training and may provide ‘Just-in-Time training. Decision makers from all responding departments will work together to provide guidance, secure necessary resources and coordinate communications internally and externally. Incident Command management provides a single recognizable focal point for emergency management enables a team response and permits a much faster response and recovery than a fragmented approach.

The UTMB Incident Commander will assume responsibility for all aspects of managing the emergency event, including: 27 | P a g e

A. Coordination of response with local agencies (fire, police), B. Notification of UTMB officials as appropriate C. Coordinating public information releases with UTMB Marketing and Communications (Public Information Officer function) D. Coordination of patient, student and employee evacuation The UTMB President is the UTMB incident commander unless authority is delegated to another official. If the President is not present at the outset of an emergency, the Incident Commander will be the highest-ranking administrative official on site.

The Incident Commander (IC) will establish an Incident Command Post (ICP) and an Emergency Operations Center (EOC) to support the ICP if necessary, The IC will identify those persons necessary to insure a rapid response and resolution to the problem (ICS Standard Form 203. Organization Assignment List or an equivalent message). The staff so identified is expected to respond to the ICP / EOC and integrate their functions with the others responding to the event. The IC will assure that all appropriate personnel are notified of the emergency situation and implementation of the Emergency Operations Plan. UTMB personnel will be contacted by:  Text Message  Pager  Telephone (Master Call List and others)  Electronic mail  Public address and campus television system announcements  Any other means available, including web and social media as appropriate The UTMB Incident Commander may establish Sub-Commands as needed.

(EM.02.02.01 EOP 1) The IC will notify local government Emergency Management officials of implementation of our plan and response via telephone, fax, two-way radio or other means required. WebEOC, or other suitable electronic message protocol in general use, will be utilized for message sharing with other responders.

(EM.02.02.01 EOP 3) The location of the ICP / EOC will ordinarily be Administration Conference Rooms A and B but may be relocated depending upon the nature of the event and the need to vacate the planned space. The secondary location of the ICP / EOC is the Conference Room, General Clinical Research Center.

The TDCJ hospital falls under the authority of the UTMB Command Center.

For known events, UTMB may set up an Event Plan and an Incident 28 | P a g e

Management Team. The Event Plan will include a situational summary, an organizational assignment list, a safety plan, and a communications plan. The communications plan will address how to contact the UTMB President and key officials if a serious incident occurs. The President may choose to take over as incident commander on notification of a serious incident.

9. Local Emergency Management Coordination The IEPO will assure coordination of the UTMB emergency response with local EMS, law enforcement and fire departments, and regionally with other local healthcare providers. Appended to this plan is a list of all local hospitals, first responders, and emergency operations centers. When the UTMB Institutional Emergency Operations Plan is activated, the IIC or Program Director for Institutional Preparedness or designee will notify the appropriate authorities and/or health provider partners as shown below. This illustration is intended as a guide, and is not all inclusive of event or agency: Event (Examples only) Mass Casualty Biological Terrorism suspected

Internal Emergency (flood, fire) Industrial Accident Requiring Decontamination

Tropical weather Threat Requiring patient and Staff Evacuation

Agency or Partner Provider Mainland Center Hospital, Trauma Service Area – R (regional) hospitals Galveston County Health District Local Law Enforcement FBI CDC Galveston Fire Department CenterPoint Energy Galveston Fire/HazMat Response Team Currently GFD is only able to respond to minor HazMat incidents.

In the event of a major incident, they will contact Houston Fire Department for assistance.

Local Contractor (e.g.

Granger) Division of Emergency management State Operations Center City and County Emergency Operations Officers

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10. Regional Hospitals (Galveston County) League City: Devereaux Texas Treatment Network (Inpatient Pediatric Psych only) 1150 Devereaux Drive League City, TX 77573 (281) 335-1000 Texas City: Mainland Medical Center (Med/Surg, Adult/Geri Psych) 6801 Emmett f. Lowry Expressway Texas city, TX 77591 (409) 938-5000

11. Regional Hospitals UTMB is part of the Southeast Texas Regional Advisory Council, which includes a 25-county region in Southeast Texas. Planning, communications and coordination is accomplished primarily through SETRAC and the Catastrophic Medical Operations Center during emergencies. UTMB is also part of the Texas Medical Center. Regional assets are provided through an Emergency Medical Task Force system, which includes:     

Ambulance and Ambus mobilization Nurse Strike Teams Evacuation Support Mobile Medical Unit Biocontainment Response Unit

Houston: Memorial Hermann Hospital Southeast 11800 Astoria Houston, TX 77089 (281) 929-6100 Ben Taub General Hospital 1504 Taub Loop Houston, TX 77030 (713) 873-2000 Nassau Bay: Christus St. John Hospital 18300 St. John Drive Nassau Bay, TX 77058 (281) 333-5503 Webster: Clear Lake Regional Medical Center 500 Medical Center Blvd.

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Webster, TX 77598 (281) 332-2511 Clear Lake Rehabilitation Hospital (In-patient rehab) 655 East medical Center Blvd.

Webster, TX 77598 (281) 286-1500

12. External Communication The official spokesperson for communicating with external entities during an emergency is the UTMB Command Center Public Information Officer (PIO), or designee. All external communications will be coordinated through the PIO. At the discretion of the IC, the PIO (a Marketing and Communications team member) will contact local broadcast stations with information about the conditions at UTMB. They may also contact the Texas State Network News with official UTMB announcements. (EM.02.02.01 EOP6) The PIO will direct the process for communicating information about the general condition and location of patients to public and private entities assisting with disaster relief; and, the process, in the event of an evacuation, to release information to family, patient representatives, or others responsible for the care of the patient. (EM 02 02 01) UTMB officials will make every effort to communicate information to employees via all possible technologies and multiple radio and television stations.

Employees should stay tuned to radio and television stations to receive news concerning the latest conditions in Galveston. If there is a question about whether or not employees should return to work, they should call their supervisor check UTMB’s web site/social media channels, or call the UTMB information hotline at (409) 77-ALERT. Patient Information: In emergency situations, infectious disease outbreaks or when criminal acts such as bioterrorism have been committed, patient information may be transmitted to appropriate third parties in accordance with laws protecting patient information confidentiality. During infectious disease outbreaks UTMB will release information to official public health authorities in accordance with law. During emergency evacuations, patient identification information will be entered into the Texas Emergency Tracking Network (TxETN) (formerly Texas Special Needs Evacuation Tracking System (TxSNETS)) system or EM Resource in accordance with the State Medical Special Needs Evacuation Plan so that patient location can be tracked to the destination alternative care site

by RFID device and GPS. Patient Identification information will also be provided to the Catastrophic Medical Operations Center in order to locate appropriate alternate care hospitals. In all cases the release of information will comply with law. (EM.02.02.01 EOP 11) 31 | P a g e

Prior to evacuation for hurricanes, communication with alternative care sites will be done primarily through telephone, with backup communications done via WebEOC, EM Resource. For incidents without warning, communications will be done by telephone, web applications, or radio if needed. (EM.02.02.01 EOP 13)

13. Public Information Officer and News Releases The University PIO will be designated by the Office of Marketing and Communications. The IC approves news releases made by the PIO. (EM.02.02.01 EOP6)

14. Radio Stations After a weather emergency has ended, UTMB personnel and students may be called back to work through radio and local TV announcements. Employees and Students need to make arrangements to have a battery-operated radio in the event that electrical service is disrupted in your location. A list of radio stations which will be contacted to broadcast information on UTMB status is appended to this document.

15. Internal Communication System Failure In the event of an internal (telephone) hospital communication failure, either total or partial, strategically placed emergency telephones should be used. Should they fail or not be available, portable two-way radios will provide an effective internal communication system. Distribution of these radios will be made by the IC /designee.

In the event of an unexpected telephone failure affecting parts or all of the hospitals between the hours of 5 pm and 8 am, or on weekends and holidays, the Clinical Operations Administrator may gain access to the emergency radio units by contacting Program Director for Institutional Preparedness.

16. Activation of Weather Plans - Executive Decision The following procedures are designed for hurricanes and may be adapted as needed for other weather emergencies. Upon notification of imminent dangerous weather conditions the IEPO, and the UTMB President or Health System Chief Executive Officer or designee will determine the possible adverse impact the weather situation may have on the operations of the Health System.

(EM.02.01.01 EOP5) The President, or IC and the Chief Academic Officer or designee and/or appropriate dean(s) will determine the impact of the weather situation on the academic areas.

The President, or IC and the Executive Vice President for Business or designee 32 | P a g e

will determine the possible impact of the weather situation on the administrative and business departments.

A. Procedure The President or designated IC will activate the Emergency Operations Plan 1. Activation is an administrative decision.

2. Activation may be in advance of National Weather Service reports and warnings, or with those orders issued by the City of Galveston. Staff should not make assumptions based on National Weather Service Hurricane watches and warnings, but instead depend on official announcements from UTMB on plans to evacuate.

UTMB contracts for weather forecasting services from StormGeo which provides the following information to aid in decision making in advance of major storms and may be used as trigger points for Emergency Operation Plan activation:  UTMB site Response Plan Activator (RPA): a positive RPA- may be used to identify a hurricane threat specific to the UTMB campus  Hurricane Severity Index (HSI): a 1-50 point scale that indicates the severity of the storm in terms of both wind and storm surge.  Probability of Wind Impact greater than 58 miles per hour (PWI)  Forecast Time of Arrival of sustained winds (FTA) o Greater than 39 miles per hour o Greater than 58 miles per hour  Worst Case Scenario (WCS): a timeline to UTMB in case the forecast track changes  Forecast Surge Inundation (FSI) This information is available at http://www.stormgeo.com/impactweather and will be emailed to UTMB when the UTMB Galveston campus is positive for the Response Plan Activator Triggers should always consider the size of the wind field and the speed of movement of the storm and not just the Saffir - Simpson scale forecast of wind speed or a 120 hour timeline to the arrival of gale force winds.

Plan Acceleration: A large Hurricane Severity Index may be used in accelerating the progression through response stages. A large Hurricane Severity Index would indicate that a large and powerful wind field and a strong storm surge is expected. In this case, UTMB leadership may choose to accelerate through the preparedness stages more quickly in order to assure the safety of patients, students, and staff.

For examples of trigger points using the information listed above, see the Patient 33 | P a g e

Evacuation Appendix.

The following steps for initiating the weather plan are general, and thus allow flexibility in the department or area-specific plans. UTMB may decide to evacuate in advance of a mandatory evacuation order issued by the City or any jurisdiction.

Activation of the UTMB plan will set into motion the internal weather plan which each school, department, institute, and service area has devised. Note that these time slots such as 120 – 60 hours are a guide and that in real emergencies, 120 hours may not be available and timelines and checklists will need to be adjusted accordingly. More accurate triggers for emergency response are listed in the Triggered Phase Response Plan.

For any UTMB campuses located outside of Galveston County, the Campus Emergency Preparedness Officer should coordinate with local emergency preparedness officials.

17. Evacuation of Visitors When an Emergency Weather Plan for hurricanes is activated by the President, the Health System CEO or a designee should advise (as appropriate to the weather conditions) that elective admission patients and visitors leave the hospital. Based on the severity of weather conditions, elective admission patients may be told to leave immediately. Visitors who refuse to leave should be reported to the IC. Where possible, persons visiting patients in the hospital should be asked to provide transportation for elective admissions being discharged.

18. Academic Weather Plan For information about the Academic Weather Plan, refer to: •

School of Medicine Weather Plan http://www.som.utmb.edu/Weather_Plan/SOM_Weather_TOC.htm

•

School of Nursing Weather Plan http://www.son.utmb.edu/weather/weather.htm

•

School of Health Professions Plan http://shp.utmb.edu/Dean/emergency.asp

19. Research Weather Plan Research areas should follow the weather / Continuity plan of their departments, centers or institutes. Pre-weather emergency communications regarding specific issues may be communicated by the research list serve, as well as other UTMB communication media.

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20. Business Departments / Non-Academic, Non-Clinical Areas All Business departments shall become familiar with the general provisions of the Institutional Emergency Operations Plan and the Staffing During Adverse Events Policy (Policy 3.1.1 in the UTMB Institutional Handbook of Operating Procedures).

Business departments with specific responsibilities during weather or other emergencies must have written departmental plans outlining their responsibilities and related procedures.

21. Personnel Accommodations (EM.02.02.07 EOP5) For the main UTMB Campus in Galveston: Sleeping quarters will be provided for essential personnel remaining on duty during the emergency by their respective hospital department to the extent possible.

Staff members with private offices or access to other convenient departmental areas are expected to utilize those areas for sleeping quarters if those buildings remain open. The annual UTMB Disaster Plan map will indicate which buildings are planned to be open and with emergency electrical power. Additional sleeping accommodations will be located in patient care areas (in inpatient rooms or in clinic exam rooms) and room assignments will be coordinated by Human Resources (through the Logistics Section of the Incident Command).

For other UTMB Campuses: Staff sheltering plans will be developed based on the suitability of the building structures, provisions for emergency power and utilities, and the nature of the incident.

22. Parking for Essential Personnel (EM.02.02.07 EOP5) For the main UTMB Campus in Galveston: UTMB Police will make all UTMB parking garages available to essential personnel, free of charge, for the duration of the emergency. Spaces will be given to essential personnel with Official (Orange, Laminated) E-1 parking permits. Parking should be avoided on the 1 st level of all parking garages and surface lots.

For other UTMB Campuses: Parking areas will be designated by the Campus Emergency Preparedness Officer.

23. Accommodations for Dependent Family Members (EM.02.02.07 EOP 5, 6) Authorization for housing of employees’ family members must be secured from the President in advance. A written request must be made, by the academic or clinical department chairman, or the appropriate university department head or dean of the department. Exceptions allowing dependent housing will be provided 35 | P a g e

during emergency weather conditions only if one of the following categories applies.

A. An Essential employee is a single parent responsible for a child or adolescent, and is unable to make other arrangements for housing.

B. Two Essential employees are responsible for a child or adolescent, and are unable to make alternate arrangements for housing.

C. An Essential employee is responsible for a frail or elderly family member, and is unable to make alternate arrangements for housing.

Dependents are expected to be self-sufficient and bring all required food, water, medications, bedding and personal convenience items. Housing for dependents will be determined at the time of the emergency plan activation and employees will be told where to bring the dependent. All dependent needs are the responsibility of the employee.

Any employee granted an exception related to dependents will receive written approval from the President

24. Not Allowed – Appliances, Pets (EOP.02.02.07 EOP5) Under no circumstances may any electrical appliances or combustible fuelpowered appliances, e.g., propane camp stoves or lanterns, candles or similar items, be brought into the hospitals or other university building.

Hospital or academic space may not be used for housing pets.

25. House Staff and Faculty Accommodations (EOP.02.02.07 EOP5) Accommodations for the house staff, faculty, and their authorized dependents will be in accordance with the Staff Sheltering Plan developed by the UTMB Command Center – Logistics Section Chief. The Logistics Section Chief will coordinate with other campuses to assure that staff sheltering plans are in place.

26. Bedding (EM.02.02.07 EOP5) .

UTMB has a staff shelter plan. Sleeping areas with cots and linens will be provided by the Hospital Incident Command Logistics Section.

27. Scrubs (EM.02.02.07 EOP5) For UTMB Main Campus: During a weather emergency, scrub suits will be issued via the “Auto Valet System” to employees in specific departments only.

These departments include, but are not limited to, staff in the Emergency Department, the Operating Room Suite and Labor and Delivery / Birthing Center.

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28. Dietary Provisions (EM.02.02.07 EOP5) The Logistics Section will ensure that supplies in-stock, on campus are sufficient.

The Logistics Section must establish an alternate location to preclude the possibility of supplies being ruined by rising water. Optional location(s) should be included in the departmental emergency weather plan. Food service vendors will be notified of the number of staff remaining on campus, and vendors will notify the ICP of the number of staff that they will have on campus.

For Notice incidents such as hurricanes, the Logistics Section Chief will assure that all UTMB campuses have sufficient supplies on hand.

29. Ancillary Services (EM.02.02.07 EOP5) During some weather emergencies, all ancillary services will be on emergency (reduced) staffing. Requests for tests should be limited to those that are medically necessary for care of patients for the duration of the emergency status.

Ancillary departments will report any service restrictions to the IC who will assure distribution to all affected areas.

30. Hospital Personnel Availability (EM.02.02.07 EOP5) Uninterrupted patient care and assuring patient safety are our primary concerns and responsibilities regardless of the adverse events that confront normal operations. All hospital employees have a professional obligation and commitment to be available during periods of adverse weather conditions.

Hospital personnel are not authorized to leave work due to weather conditions or activation of any phase of the Emergency Operations Plan without specific approval.

Employees who fail to report for scheduled work because of weather conditions without the approval of their department head/supervisor will be considered to be taking an unauthorized absence.

Each service area (or department) will be responsible for assuring adequate numbers of support personnel, nurses, faculty or house staff physicians or other staff are assigned to provide critical services of that area or department, or provide care for patients hospitalized during an event or expected to be admitted as a result of the event.

For the Main UTMB Campus: The UTMB Health System maintains a Hospital Evacuation Sequence to assure that the patient evacuation takes place in an orderly way, and that sufficient staff members are on hand throughout the whole evacuation process. Nursing staff should not assume that they can leave once their area is evacuated. They may be assigned to assist in the evacuation of patients from other areas.

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31. Release of Personnel Before a Weather Emergency Supervisors may not release personnel from their assigned duties until instructed to do so by the President, the IEPO or the IC. Any supervisor deviating from official policy in personnel and payroll management while the institution is in emergency operational status is subject to disciplinary action including termination.

During an emergency/disaster, UTMB Policy 3.1.1 “Staffing During Adverse Events” shall apply regarding leave.

32. Evacuation of University – Catastrophic Prediction If forecast conditions are determined to be unsafe to continue to manage university operations locally, the ICP / EOC may be relocated to another safe location. In this situation a minimal team of UTMB personnel will shelter-in-place in the most safe and secure location available. All others will be evacuated to an alternate location controlled by UTMB, secured under the UT System Interagency agreement or available through local emergency management officials.

Arrangements will be made to assure communications from campus to the alternate location and to assure return of university officials as quickly as possible when conditions permit safe travel.

Discontinuation of emergency operations will be broadly communicated by all available media in order to reach all displaced UTMB staff and other interested persons. The IC will notify city, county and state emergency preparedness officials of the date and time UTMB discontinues emergency status and resumes normal operations. Information on return to work and/or resumption of classes in UTMB schools will be included in public service messages and broadcast announcements.

33. Disaster Privileges to Volunteer Licensed Independent Practitioners (EM.02.02.13 EOP1) For all UTMB Campuses: As a state agency, UTMB will normally seek staffing assistance from other state agencies and other UT medical institutions and will not seek to use volunteers. In the case that UTMB does have the need for volunteers; UTMB would only grant privileges to volunteer licensed independent practitioners only when the Emergency Operations Plan has been activated.

Plans to accept volunteers include Texas Emergency Medical Task Force Members and federal Disaster Medical Assistance Teams (EOP 14)

34. Requesting an 1135 Waiver (EM 02 01 01 EOP 14) Definition of an 1135 Waiver When the President declares a disaster or emergency under the Stafford Act or National Emergencies Act and the HHS Secretary declares a public health emergency under Section

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319 of the Public Health Service Act, the Secretary is authorized to take certain actions in addition to her regular authorities. For example, under section 1135 of the Social Security Act, she may temporarily waive or modify certain Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) requirements to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in Social Security Act programs in the emergency area and time periods and that providers who provide such services in good faith can be reimbursed and exempted from sanctions (absent any determination of fraud or abuse). Examples of these 1135 waivers or modifications include:  Conditions of participation or other certification requirements  Program participation and similar requirements  Preapproval requirements  Requirements that physicians and other health care professionals be licensed in the State in which they are providing services, so long as they have equivalent licensing in another State (this waiver is for purposes of Medicare, Medicaid, and CHIP reimbursement only – state law governs whether a non-Federal provider is authorized to provide services in the state without state licensure)  Emergency Medical Treatment and Labor Act (EMTALA) sanctions for direction or relocation or of an individual to receive a medical screening examination in an alternative location pursuant to an appropriate state emergency preparedness plan (or in the case of a public health emergency involving pandemic infectious disease, a state pandemic preparedness plan) or transfer of an individual who has not been stabilized if the transfer is necessitated by the circumstances of the declared emergency. A waiver of EMTALA requirements is effective only if actions under the waiver do not discriminate on the basis of a patient’s source of payment or ability to pay.  Stark self-referral sanctions  Performance deadlines and timetables may be adjusted (but not waived).  Limitations on payment for health care items and services furnished to Medicare Advantage enrollees by non-network providers These waivers under section 1135 of the Social Security Act typically end no later than the termination of the emergency period, or 60 days from the date the waiver or modification is first published unless the Secretary of HHS extends the waiver by notice for additional periods of up to 60 days, up to the end of the emergency period. Waivers Revised: November 4, 2009 for EMTALA (for public health emergencies that do not involve a pandemic disease) and HIPAA requirements are limited to a 72-hour period beginning upon implementation of a hospital disaster protocol. Waiver of EMTALA requirements for emergencies that involve a pandemic disease last until the termination of the pandemic-related public health emergency. The 1135 waiver authority applies only to Federal requirements and does not apply to State requirements for licensure or conditions of participation.

Other Flexibilities In addition to the 1135 waiver authority, Section 1812(f) of the Social Security Act (the Act) authorizes the Secretary to provide for skilled nursing facility (SNF) coverage in the absence of a qualifying hospital stay, as long as this action does not increase overall program payments and does not alter the SNF benefit’s “acute care nature” (that is, its

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orientation toward relatively short-term and intensive care).

Determining if Waivers Are Necessary In determining whether to invoke an 1135 waiver (once the conditions precedent to the authority’s exercise have been met), the Assistant Secretary for Preparedness and Response (ASPR) with input from relevant OPDIVS determine the need and scope for such modifications. Information considered includes requests from Governor’s offices, feedback from individual healthcare providers and associations, and requests to regional or field offices for assistance.

How States or Individual Healthcare Providers Can Ask for Assistance or a Waiver Once an 1135 Waiver is authorized, health care providers can submit requests to operate under that authority or for other relief that may be possible outside the authority to the CMS Regional Office with a copy to the State Survey Agency. Request can be made by sending an email to the CMS Regional Office in their service area. Email addresses are listed below.

Information on your facility and justification for requesting the waiver will be required.

Review of 1135 Waiver requests CMS will review and validate the 1135 waiver requests utilizing a cross-regional Waiver Validation Team. The cross-regional Waiver Validation Team will review waiver requests to ensure they are justified and supportable.

Implementation of 1135 Waiver Authority Providers must resume compliance with normal rules and regulations as soon as they are able to do so, and in any event the waivers or modifications a provider was operating under are no longer available after the termination of the emergency period.  Federally certified/approved providers must operate under normal rules and regulations, unless they have sought and have been granted modifications under the waiver authority from specific requirements.

35. Replenishment of Critical Supplies The Logistics Section Chief is responsible for planning for the replenishment of critical supplies, including both medical and non-medical supplies. (EM 02 02 03)

36. Tracking Staff During Emergencies The UTMB Command Center will use Incident Command System Resource Management principles to track staff during emergencies. Tools such as sign in sheets and status boards may be used to help track staff members that are on duty and their location. Staff shelter areas will maintain a roster of current occupants. Demobilization should account for all staff. (EM 02 02 07)

37. Emergency Provision of Critical Utilities (EM 02 02 09) Of the three campuses, UTMB Main Campus is at the greatest risk to hurricane damage. The Jenny Sealy Hospital is the most robust hospital facility on main campus. In order to best protect the life and safety of staff and patients, the UTMB Command Center may choose to consolidate 40 | P a g e

patients into this facility. Jenny Sealy provides emergency power and lighting as well as critical utilities such as cooling. (EM 02 02 09) For renovations or new construction, all emergency power systems and critical components are to be placed above base flood level or higher. (EM 02 02 09 EOP 9)

V. Recovery (EM.02.01.01 EOP4) 1. Damage Assessment and Repairs; Debris Removal (There is a detailed UTMB Recovery Annex to this plan in the Emergency Planning I-Space Folder. There is also a Recovery Plan specific to Ambulatory Services in I-Space) The Support Operations Section /BOF will conduct campus wide damage assessments and identify critical needs for repairs, additional power or air conditioning. BOF will coordinate the ordering of repair supplies and contract labor to effect repairs. Debris removal, if required will be coordinated by BOF who will be responsible for securing contract services, equipment, roll-off containers or other materials required. Debris removal contractors should be monitored by an independent contractor familiar with federal laws and regulations regarding compensation for debris removal. To the degree possible all contracts should include accurate scopes of work. Time and materials contracts should be avoided if possible. BOF and the IC or designees will assess any area of any UTMB building which may be compromised for occupancy and will coordinate with local building inspection officials on the decision to abandon a site, or declare any area suitable for use.

2. Volunteers For All UTMB Campuses: In general, UTMB will not seek volunteer licensed independent practitioners, or any other volunteers who are not licensed to assist in disasters. However, should this call for volunteers occur, the UTMB IC will assign these persons to Incident Command staff directly involved in patient care operations for guidance, direction and supervision. The Incident Commander or their designee, or the Chief Medical Officer is responsible for assigning disaster responsibilities to volunteer practitioners The IC or designee will verify licensure, certification, or registration if held, or other validation of their identity and competency before any work assignment is made. The primary method of oversight will be direct observation by UTMB personnel. (EM.02.02.13 EOP 6) Volunteer licensed independent practitioners: UTMB will grant disaster privileges to volunteer licensed independent practitioners only when the Emergency Operations Plan has been activated in response to a disaster and UTMB is unable to meet immediate patient needs. (EM.02.02.13 EOP 1, 4) The Chief Medical Officer (or their designee) can assign disaster privileges.

A Minimum of Two Forms of Identification: 41 | P a g e

Before a volunteer practitioner is considered eligible to function as a volunteer licensed independent practitioner, UTMB will obtain his or her valid governmentissued photo identification (for example, a driver’s license or passport) and at least one of the following: 

A current picture identification card from a health care organization that clearly identifies professional designation



A current license to practice



Primary source verification of licensure



Identification indicating that the individual is a member of a Disaster Medical Assistance Team (DMAT), the Medical Reserve Corps (MRC), the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP), or other recognized state or federal response organization or group



Identification indicating that the individual has been granted authority by a government entity to provide patient care, treatment, or services in disaster circumstances



Confirmation by a licensed independent practitioner currently privileged by the hospital or by a staff member with personal knowledge of the volunteer practitioner’s ability to act as a licensed independent practitioner during a disaster (EM.02.02.13 EOP 5)

Based on its oversight of each volunteer licensed independent practitioner, the hospital determines within 72 hours of the practitioner’s arrival if granted disaster privileges should continue. (EM.02.02.13 EOP 7) Oversight will be by direct observation.

Primary source verification of licensure must occur as soon as the disaster is under control or within 72 hours from the time the volunteer licensed independent practitioner presents him- or herself to the hospital, whichever comes first. If primary source verification of a volunteer licensed independent practitioner’s licensure cannot be completed within 72 hours of the practitioner’s arrival due to extraordinary circumstances, UTMB documents all of the following: - Reason(s) it could not be performed within 72 hours of the practitioner’s arrival - Evidence of the licensed independent practitioner’s demonstrated ability to continue to provide adequate care, treatment, and services - Evidence of the hospital’s attempt to perform primary source verification as soon as possible (EM.02.02.13 EOP 8) If, due to extraordinary circumstances, primary source verification of licensure of the volunteer licensed independent practitioner cannot be completed within 72 hours of the practitioner’s arrival, it is performed as soon as possible. Note: 42 | P a g e

Primary source verification of licensure is not required if the volunteer licensed independent practitioner has not provided care, treatment, or services under the disaster privileges. (EM.02.02.13 EOP 9) Volunteer Licensed Independent Practitioners will be identified by either temporary badges or vests. (EM 02 02 07 EOP 9) Un-licensed independent volunteer practitioners: UTMB assigns disaster responsibilities to volunteer practitioners who are not licensed independent practitioners only when the Emergency Operations Plan has been activated in response to a disaster and the hospital is unable to meet immediate patient needs. (EM.02.02.15 EOP1) The Incident Commander or their designee, or the Chief Medical Officer is responsible for assigning disaster responsibilities to volunteer practitioners who are not licensed independent practitioners.

(EM.02.02.15 EOP2) UTMB will distinguish volunteer practitioners who are not licensed independent practitioners from its staff through the use of vests or badges. (EM.02.02.15 EOP3) UTMB will oversee the performance of volunteer practitioners who are not licensed independent practitioners who have been assigned disaster responsibilities through direct observation, mentoring, and medical record review. (EM.02.02.15 EOP4) Before a volunteer practitioner who is not a licensed independent practitioner is considered eligible to function as a practitioner, UTMB will obtain his or her valid government-issued photo identification (for example, a driver’s license or passport) and one of the following: 

A current picture identification card from a health care organization that clearly identifies professional designation



A current license, certification, or registration



Primary source verification of licensure, certification, or registration (if required by law and regulation in order to practice)



Identification indicating that the individual is a member of a Disaster Medical Assistance Team (DMAT), the Medical Reserve Corps (MRC), the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP), or other recognized state or federal response organization or group



Identification indicating that the individual has been granted authority by a government entity to provide patient care, treatment, or services in disaster circumstances



Confirmation by hospital staff with personal knowledge of the volunteer practitioner’s ability to act as a qualified practitioner during a disaster

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(EM.02.02.15 EOP5) During a disaster, UTMB will oversee the performance of each volunteer practitioner who is not a licensed independent practitioner. Such volunteers will be assigned duties at the Incident Command Post and their work will be directly supervised by UTMB personnel. (EM.02.02.15 EOP6) Based on its oversight of each volunteer practitioner who is not a licensed independent practitioner, the hospital determines within 72 hours after the practitioner’s arrival whether assigned disaster responsibilities should continue. (EM.02.02.15 EOP7) Primary source verification of licensure, certification, or registration (if required by law and regulation in order to practice) of volunteer practitioners who are not licensed independent practitioners will occur as soon as the disaster is under control or within 72 hours from the time the volunteer practitioner presents himor herself to the hospital, whichever comes first. If primary source verification of licensure, certification, or registration (if required by law and regulation in order to practice) for a volunteer practitioner who is not a licensed independent practitioner cannot be completed within 72 hours due to extraordinary circumstances, UTMB will document all of the following: - Reason(s) it could not be performed within 72 hours of the practitioner's arrival - Evidence of the volunteer practitioner’s demonstrated ability to continue to provide adequate care, treatment, or services - Evidence of UTMB’s attempt to perform primary source verification as soon as possible. (EM.02.02.15 EOP8) If, due to extraordinary circumstances, primary source verification of licensure of the volunteer practitioner cannot be completed within 72 hours of the practitioner's arrival, it is performed as soon as possible. Note: Primary source verification of licensure, certification, or registration is not required if the volunteer practitioner has not provided care, treatment, or services under his or her assigned disaster responsibilities. (EM.02.02.15 EOP9)

3. Emergency Recovery - Crisis Support Assistance (EM.02.02.07 EOP5) UTMB disaster recovery efforts are enhanced by the availability of trained volunteer crisis support professionals. UTMB will provide support as necessary for our employees, volunteers and students who have responded to an emergency event, who have supported others who responded, or who otherwise need assistance during stressful periods. Damage to property, loss of possessions, waiting for financial assistance and material relief are extremely stressful. Trained volunteers and UTMB staff can be mobilized to assist employees in recovery from traumatic events. Even those who suffer little or no material loss may experience external and self-imposed tensions. These services are provided by the UT’s Office of Employee Assistance Program Trained staff will be present in the UTMB Emergency Operations Center to assess needs and coordinate response to requests. If required, UTMB will request additional counselors through UT System Inter-agency Agreements .

(EM 02 02 11 EOP 6) 44 | P a g e

4. Post Event Procedures Following any use of the plan, the IC or IC’s designee will convene a meeting of all involved/affected personnel for the purpose of debriefing the incident. This meeting shall identify components of the plan which worked well and identify (1) areas for improvement and (2) changes to the plan or to university or departmental policies indicated in the experience. The IC /designee will be responsible for monitoring progress of groups responsible for implementing changes.

University facilities may only be reopened and reoccupied when the all-clear notice is issued by the President or IC. Unsafe or contaminated areas must be reported to EH&S before commencing business operations. The Texas Division of Emergency Management may also be contacted for assistance.

5. Return to Regular Work Schedule (EM.02.01.01 EOP5) The specified time for UTMB employees to resume their regular work schedules will be communicated throughout the state through designated radio and TV stations. Call-in numbers through which to obtain this information will also be provided. It is the employee’s responsibility to monitor the media for these announcements. (See section titled “Radio Stations” for listing of designated statewide stations that will carry official UTMB messages.) The UTMB President may delegate the authority to announce back-to-work announcements to Campus Emergency Preparedness Officers. If possible, these messages should be coordinated with the UTMB Institutional Public Information Officer.

Regular work schedules can only be resumed when a general “All Clear” message is announced by the IEPO or designee. If the emergency was unique to one entity, the resumption of normal operations will be coordinated by the IC and announced by: A. Hospitals and Clinics – Vice President and Chief Executive Officer for Hospital and Clinics or designee (Healthcare Operations Chief); B. All Schools – Chief Academic Officer or designee (Academic/Research Operations Section Chief); C. Administration and Business offices and Other Entities (e.g.

Correctional Managed Care) – Entity Vice President or Leader or their designee (Support Operations Section Chief).

6. Leave After the Emergency Emergency administrative leave for handling serious personal problems after normal operations are resumed, e.g., extensive home damage, will be granted on an individual basis by forwarding requests through appropriate administrative channels. Final approval will be through the Office of the President.

Record of Changes 45 | P a g e

9 Dec 2011 Page 12: Add Institutional Safety and Security Executive Committee Page 30: Replace Office of University Advancement with Public Affairs Page 33: Clarified City of Galveston preparedness levels Page 39: Added emphasis that two forms of identification are required for volunteer Licensed Independent Practitioners Page 40: Added a section to say that Volunteer Licensed Independent Practitioners will be identified by either temporary badges or vests. (EM 02 02 07 EOP 9) (Added by Mike Mastrangelo, Program Director, Institutional Preparedness) Feb 27, 2014: Amended to account for additional campuses by Mike Mastrangelo, Program Director, Institutional Preparedness. Changes approved by the Institutional Safety and Security Executive Committee September 21, 2015 Page 6 – Added reference to League City Campus Page 10 – deleted references to location of healthcare services based on opening of CSW Page 18-19 – Clarified the role of the Health System Administrator On-Call for ‘No-Notice’ Incidents Page 20 – Added League City Campus Page 28 and throughout – Updated name of University Advancement to ‘Marketing and Communications’ Page 29 – Included ‘Text Message’ as a method of communications Page 33 – Updated Impact Weather to ‘StormGeo’

Updates 21 December 2017, by Institutional Safety and Security Executive Committee Scope amended to change institutional plan to Integrated Emergency Preparedness Program which has the same meaning but follows Joint Commission language.

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An old reference to City of Galveston Hurricane plans was deleted. A reference to UTMB’s evacuation plan was deleted since there is a separate institutional hurricane evacuation plan.

UTMB Police corrected language related to their accreditation.

A section on 1135 Waiver request processing was added.

Updates 15 April 2019, by Mike Mastrangelo Cover Page – Removed Calendar Year 2018 Page 4 – Added Clear Lake Campus Page 24 – Added Clear Lake Campus

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