Disaster PreparednessLessons Learned from the Unexpected

Bob Loeper, VP Operations Support

Business Continuity/Disaster Response

Fresenius Kidney Care

July 18-20, 2019

Table Top Exercise –

Disaster Response 2019

ObjectivesDescribe the types of disasters that can impact the care of a renal patient and the preparation required in order to minimize the impact.

Discuss the Lessons Learned from the 2018 Hurricane Season

Identify pre and post disaster tasks required to ensure patients and staff safety and basic needs are met.

Discuss purpose and staffing of an “Incident Command Center”.

Review update CMS Interpretation Guidelines and most common CMS E-Tag Citations

About Fresenius Medical Care NA• 2500 outpatient dialysis centers serving 160,000 US ESRD

patients • Supply ~90% of industry with renal products and equipment• 25 full risk ESCO market contracts with CMS• Care Navigation Unit• Renal Specialty Pharmacy in Nashville and St Petersburg• Med Spring Urgent Care Centers• Cardio Vascular Centers• Azura Care Vascular centers • Spectra Lab

Fresenius Disaster Response TeamMission Statement

To save lives of all patients and staff and mitigate property damage through education and training on emergency preparedness

• Hide from wind, run from water▪ 83% deaths are water related

• Go around, don’t drown• When in doubt, take another route• Know your evacuation route and flood zone• Evacuate miles, not hundreds of miles• An Informed community is prepared, a prepared community is

resilient

• Develop an emergency plan based on a risk assessment;• Use an “all-hazards” approach;• Allows for an Integrated system for emergency planning;• Focuses on capacities and capabilities.

Risk Assessment and Planning

• Develop and implement policies and procedures based on the emergency plan and risk assessment that are reviewed;

• Updated at least annually.

Policies and Procedures

• Develop/maintain a communication plan; • Complies with Federal and State law. • Coordinate patient care within the facility and across health care

providers in the community

Communication Plan

• Develop and maintain training and testing programs;• Including training on policy and procedures;• Dialysis facilities to conduct drills/exercises to test plans.

Training and TestingC

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EOC Sponsored Community Drills• Hurricane Moultrie, SC statewide drill▪ Cat 4 strikes north of Charleston▪ Simulate closing of all clinics east of 95▪ Surge to other clinics and shelters▪ Transportation companies simulated patient pick up/drop off shelters

• Hillsborough County Dimethyl Sulfide Derailment gas cloud▪ 110 organizations responded to drill▪ FKC used trash bags with saline to seal doors, Shelter in Place ▪ Injects include power lose and no oxygen in ERs

• Hurricane Smith, Cat 3 strikes Naples and then over to Palm Beach County

Disaster Preparedness and Response Activity

• California Fires • Water Contamination• Hurricane Florence • Hurricane Michael• Alaska Earthquake

California Wildfires• The only disaster we actually go after to diffuse• CA mitigation expense were $400M in 2017, $2.0B in 2019• Feds want local Govt to foot more of the bill so they get

tougher on building permits, tree trimming and controlled burns

• CA Real Estate transactions now require a wildfire prevention inspection of the property

Mitigation Strategies for California Wild Fires

• Close the fresh air intake to 95% • Replace the existing pleated air filter(s) with new pleated air filter• Install disposable activated carbon air filter as a pre-filter up stream of the

newly installed pleated air filter.• Place multiple self-contained 110 volt carbon ionizer air cleansing units.• Inform/remind Fire Department of generator diesel tanks, consider off

loading fuel if fire imminent. • Turn generator off if commercial power is to be terminated • Once exterior air quality returns to normal remove air cleansing units and

remove and dispose of activated carbon pre-filter▪ Inspect pleated air filter(s) and replace as necessary

Louisa, VA Water Contamination • On December 3, 2018 city announces water not safe to drink

▪ Contaminated with unknown industrial solvent▪ EPA, State Environmental Health involved and testing water▪ Fresenius conducted own water tests▪ Two weeks until water tested as potable ▪ No identification of contaminate source determined

• Patients transported to nearest FKC faculty 40 miles away for 2 weeks▪ Some patients transferred to Non FKC clinic nearby on different water source▪ Issues with missed treatments, patient inconvenience, increased hospitalizations ▪ Water tankers on standby, but pretreatment was already contaminated

Louisa, VA Water Contamination • All water pre-treatment media replaced▪ Multi media, carbon, softener ▪ Replaced RO Membranes▪ Disinfect, replace machine Diasafe filters

• Machines cultured and requalified• Many patient complaints of process to ensure safe water • Several patients transfer to nearby non FKC units• Patient Safety of upmost importance

• Florence

Hurricane Florence SC/NC • Cat 1 landfall Friday Sept 14th, slow storm ~3 MPH, 20+’’ rain over 5 days• Strom created unprecedented flooding, killing 50 people in four states • Over 4,000 patients affected with >100 clinic closures or treatment time

changes. • Staging in Atlanta with diesel tanks, gas tanks, back up generators, MIB

armed Security and campers outside of impact zone• FKC Established Command Centers in Florence, SC and New Bern, NC

• Distribution Center for staff gas, food and supplies• Personal generators were provided to our staff with no power• Provided rental cars for staff that lost their cars

Fresenius Clinic Closures During Hurricane Florence

Tentative Closing Dates

9/11/2018 9/12/2018 9/13/2018 9/14/2018 9/15/2018 Grand Total

SOUTH CAROLINA 7 38 9 1 55

EASTERN NORTH CAROLINA 1 3 49 1 54

WESTERN NORTH CAROLINA 8 4 12

EAST VIRGINIA 3 6 9

SOUTH GEORGIA 4 3 7

SOUTHEAST REGION 6 6

RRI MANAGED 5 5

Grand Total 1 10 96 33 8 148

Lessons Learned from Florence• Know re entry requirements post storm▪ Picture IDs for staff

• Strom surge and flooding more dangerous than wind• Coordinate/ triage ESRD patients with Hospitals ▪ If only needing dialysis, refer to FKC Patient Emergency Hotline▪ Fresenius provided transportation services

• Locate and use of volunteers• Bring oxygen tanks on patient rescues• Patients refused to evacuate, challenge to locate afterwards

Homeland Security Re-Entry AuthorizationLocal EOC Requirements must be Verified

Fresenius Authorization LetterTo Whom It May Concern:

The individual carrying this letter is authorized by the National Incident Commander for Fresenius Medical Care North America to respond to the medical and infrastructure needs of patients who require life sustaining medical treatment in a Fresenius Medical Care facility. As such, this individual should be allowed to travel freely and without interruption or interdiction to and from whatever location that requires his/her assistance.

If you require any further authorization or information, please contact me immediately at

813-843-4423.

Robert P Loeper

National Incident Commander APPROVED by

Fresenius Medical Services EoC/ FEMA (stamped)

Disaster Response Team

Vice President of FMS Strategic Project Management

As of Monday 7

AM

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April 2017 (before) October 2018 (after)14 ft storm surge

Hurricane Michael• First Category 5 Hurricane to hit US since 2005 ▪ 155 MPH October 12, 2018 hits Panama City and Mexico Beach▪ 3rd most powerful Hurricane to make landfall in US History ▪ First Cat 3 to hit Georgia since 1800s ▪ $30 B in damages

• Rapidly developed from Cat 3 to Cat 5 in 1 day• Mandatory evacuation issued too late to be effective• 32 deaths attributed to Hurricane Michael across the eastern seaboard • 10,000 remain homeless today • Impacts were felt from GA through VA

Response to Hurricane Michael• Established 2 Command Centers in Panama City and Blairsville ▪ Incident Commanders and support teams arrive from outside of

Florida ▪ Distribution points for supplies, food and gas for staff▪ Diesel and water tankers ▪ Men in Black Security Services at all Command Centers ▪ Track and account for all patients and staff▪ FKC Panama City clinic only minor damage

o Operational within 2 days

Lessons Learned Michael• Use outside Leadership teams for Command Center posts▪ Use RV as Command Post, not clinic conference room

• Pre- register patients at special needs shelters• Confirm backup clinic is operational• Home patients stock up on CAPD supplies• Additional oxygen tanks on board prior to storm• Provide long term housing for staff or they will leave area • Track and retrieve disaster assets

Alaska Earthquake 11.30.2018

Earthquake Response• Inspect building walls and floors for cracks• Test open/close of doorways and windows for clear

movement • Track road closures, use alternate routes • Fresenius first use of First Net • Non FKC clinic was damaged and they transported all their

patients to FKC for treatment for 3rd shift each day

Overall Best Practices• Post Back Up clinic location when closing a clinic ▪ Bright color poster facing outward from interior window

• Hand out medical records to all patients prior to closing• Display the 3 day renal diet in lobby • Have copies of all staff and patients emergency contact info• Contact electrical/plumber vendors (2 deep) day before closing to

ensure availability • Coordinate closures along storm path

Overall Best Practices• Standardize reporting times and report content of clinic

closures• Properly prepare clinic for closure▪ RMW off the floor and out of shed, locked in RMW room if not

picked up ▪ All records/document off low level shelves/drawers, sealed in

water tight containers▪ Machines doubled bagged top down, bottom up▪ Equipment away from windows

Overall Best Practices

• Opening a clinic after storm, use buddy system▪ Walk the exterior first, check for building cracks; sink holes▪ One person remain outside while inside is inspected ▪ Open close windows/doors, check of jams ▪ Report any damage to leadership and claims adjuster

• Develop of Incident Command teams ready to deploy▪ Standardize roles and responsibilities of the team leads

Overall Best Practices

After Action Review• Summary of Incident▪ Include pictures, articles , news clips

• Strengths Identified• Opportunities for Improvement ▪ Gaps in your plan

• Improvement plan▪ Action Items, who is responsible, due date

• Present to QAI Committee and follow up of action items

Florida Healthcare CoalitionsEmerald Coast Healthcare Coalition (850) 863-3628 info@emeraldcoasthcc.org

Region 2 Big Bend Healthcare Coalition Ray Runo (850) 274-8601 rayruno@gmail.com

North Central Florida Healthcare Coalition northcentralflhcc@gmail.com

Northeast Florida Healthcare Coalition (904) 279-0780 info@neflhcc.org

Coalition of Health and Medical Preparedness

Region 4 Health and Medical Coalition Daniel Simpson Daniel.simpon@flhealth.gov

Central Florida Disaster Medical Coalition info@centralfloridadisaster.org

Manatee County Healthcare Emergency Preparedness Coalition

Heartland Healthcare Coalition

Suncoast Disaster Healthcare Coalition

Southwest Florida Healthcare Preparedness Coalition

Collier Healthcare Emergency Preparedness Coalition

Palm Beach County HERC (561) 733-3940 ext 17 johnj@pbcms.org

Broward County Healthcare Coalition

Miami-Dade County Healthcare Preparedness Coalition Marilia van Keeken marilia.van.keeken@smrt7.onmicrosoft.com

Monroe County ESF-8 Workgroup (305) 289-2729 help@keyshrc.org

Flood and Evacuation Zones• Flood zones are areas mapped by FEMA for use in the

National Flood Insurance Program. Each flood zone designation, represented by a letter or letters, tells homeowners exactly what the risk is for flooding at their property

• Evacuation zones are based on hurricane storm surge zones determined by the National Hurricane Center using ground elevation and the area’s vulnerability to storm surge from a hurricane. The evacuation zones are marked from A through E, plus non-evacuation zones

PinellasCountyEvacuationZones

Hillsborough County Evacuation Zones and Emergency Shelters

Should I Stay or Should I Go?

• Know your evacuation shelter location• Go miles not hundreds of miles • Defined agreed upon plan • Inform family and friends of where you plan to go

Should I Stay or Should I Go?• Board up widows• Clean tub and full with water• Freeze water bottles for ice when power goes out• Extra coolers on hand • Know personal generator safety rules ▪ Extra gas containers filled and on hand

• If water enters your house, turn off electricity at main breaker, unplug appliances

Should I Stay or Should I Go?

• Report outages of electricity • Do not turn off gas supply at main meter▪ Turn off gas appliances

• Need 3 day meal plan• Canned goods, can opener• 3 gallons of water per person per day• Cash on hand, cars gassed up

Should I Stay or Should I Go?• Hand crank weather radio and extra batteries • First aid kit• Inform family and relatives of situation • Stay away form downed power lines • Stay out of flood waters• Don’t drive through flooded streets▪ Drive around, don’t drown▪ When in doubt, take another route

Florida VOADs

Incident Command Centers• Define Command Center Roles and Responsibilities ▪ Incident Commander

o Coordinate with local EoC and provide supplies to keep clinics operational ▪ Patient Section Chief

o All Patients accountable and being treated▪ Employee Section Chief

o All staff located, assess their needs▪ Finance Section Chief

o Cost accounting of clinic level support▪ Technical Section Chief

o Distribute and retrieve DRT assets after event

Update Interpretation Guidelines• All hazard approach and HVA should also include▪ Emerging Infectious Disease (EID) threats to include Influenza,

Ebola, Zika Virus and others ▪ EIDs may require modification to facility protocols to protect

health and safety of patients o Use of isolation and PPE measures

• Make modification to alternate energy source▪ Ensure safe temperatures are maintain in patient care areas ▪ ATS or GenSet available and tested per IFU▪ Relocation or evacuation plan

Update Interpretation Guidelines

• If actual event occurred and Emergency plan was activated▪ Exempt from Community drill for 12 months

• If additional event occurred and Emergency plan was activated▪ Facility exempt from Table Top drill for 12 months

Most Common CMS Citations in 2018• Documentation of all Medical Staff Emergency Training▪ Attendings and Extenders▪ Most be Facility Specific for all Medical Staff, completed annually

• Emergency oxygen tanks empty• Communication plan with staff emergency contact information

missing newly hired staff, unsigned and not dated• No hard copy of communication plan, only electronic• Staff unaware of facility emergency plan and unable to state their

role during a disaster

Most Common CMS Citations in 2018• Facility Emergency Plan not specific to facility

▪ Need contracts of generator, diesel and water supply vendors

• Community Drills, emergency preparedness exercises not conducted• No alternate EoC Contact information• Separate Home Therapy Emergency Plan (if free standing) • HVA to include local hazards, nearby industrial plants • Emergency Evacuation box ready for use, with no expired drugs• Evacuation box must contain each patient’s treatment records

E Tags and P&Ps

Surveyor E Tag Worksheet

Any Questions?