
Emergency Management Plan
PURPOSE
Believe Therapies primarily services the pediatric population for Occupational, Physical and Speech Therapy. So, clients of all ages will be in the clinic at any given time. The EMP was developed to ensure client and staff safety at Believe Therapies during times of major emergencies and/or disasters or when such events are reasonably believed to be pending. This Emergency Management Plan was developed with consultation from the county and fire department. Believe Therapies follows Walker County Emergency Management on Facebook and Brazos County Department of Emergency Management on Facebook and Twitter for updates and real time information. An open line of communication with county officials is encouraged so Believe Therapies will be able to respond quickly and appropriately to an emergency situation.
The Brazos County contact is:
Michele Bailey-Meade
Emergency Management Coordinator
(979) 821-1011
mmeade@brazoscountytx.gov
The Walker County contact is:
Butch Davis
Emergency Management Coordinator
(936) 435-8739
It will be the responsibility of the highest ranking staff person on duty to declare a situation a disaster and initiate the disaster and evacuation policy and procedure.
A disaster/emergency plan is implemented under the following circumstances, as identified by Believe Therapies’ Emergency Risk Assessment:
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Fire
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Tornado
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Winter Storm
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Domestic Dispute
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Prison Break
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Missing Child
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Emerging Communicable Diseases
FACILITY PREPARATION
The initial risk assessment was completed on October 9, 2018. A copy of the most current Risk Assessment is attached as Appendix A. The risk assessment will be updated annually in October.
EMERGENCY RESPONSE ROLES
A County Official and a Fireman were consulted during the development of Believes’ Emergency Management Plan. Believe Therapies is not equipped to respond definitively to all disasters. However, the organization may play a role in responding to a disaster including but not limited to:
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Providing temporary shelter
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Closing the clinic in order to move staff/clients to other safe locations or the hospital that are more appropriate to handle the situation
Each role listed in the response Chain of Command has specific duties that need to be implemented. Although there are specific personnel that would be best to fill a position, they may not necessarily be on site when a disaster might occur; therefore, each job does not necessarily require a specific person to fill the position.
In addition, one person may need to take responsibility for the functions of more than one job until relieved. The main priority is to begin various job functions until more qualified people are available to fulfill these duties.
Information/Planning Manager – Gathers facts and provides information on the status of the disaster/emergency situation. Projects short term needs for the situation, as necessary.
College-Station Clinic
Name: Kinsey Johnson
Cell Phone: 979-255-9953
Huntsville Clinic
Name: Jenna Thomas
Cell Phone: 936-662-7847
Designated Incident Command Manager – Manages and directs the overall response functions.
College-Station Clinic
Name: Melanie Dimas
Cell Phone: 979-402-3666
Huntsville Clinic
Name: Jennifer Schoenthaler
Cell Phone: 936-240-5418
Succession Incident Command Manager – Responsible for Incident Command in the event the initial designee is unable to assume the responsibility.
College-Station Clinic
Name: Amanda Bond
Cell Phone: 361-318-3135
Huntsville Clinic
Name: Sarah Alaway
Cell Phone: 806-440-5009
INVENTORY OF EMERGENCY RESOURCES
An Emergency Resources Box will be supplied and kept in a designated spot within each clinic. The Emergency Resource Box includes (Appendix B):
Flash Light(s)
Back up batteries
First Aid kit
EMERGENCY RESOURCE CALL LIST
Attachment in Appendix C
STAFF CALL PROTOCOL
The local Sherriff’s Office is the point of contact for Emergency Management Operations. This is part of a Comprehensive Emergency Management Program that is designed to reduce the vulnerability of the citizens to damage, to injury, and to loss of life and property by providing a system for the MITIGATION of, PREPAREDNESS for, RESPONSE to and RECOVERY from natural or man-made disasters. The emergency resource call list (Appendix C) has telephone numbers of staff for emergency contact and is located by each phone in the clinic. During an emergency, the Clinical Administrator or designee is responsible for contacting involved staff. The alternate contact person is: The Clinical Coordinator at each clinic in the event the Clinical Administrator is not on duty or unavailable.
CLIENT/FAMILY NOTIFICATION
In the event an emergency protocol is activated, the receptionist is responsible for notifying the clients/guardians. The Clinical Administrator may assign additional staff to assist with contacting the clients/guardians as necessary. A list of clients and phone numbers can be found in the EMR system.
SHELTER IN PLACE
If there is an imminent threat or hazard, the public may be told to “shelter in place.” This is a precautionary routine to keep everyone as safe as possible during an emergency event. Situations that may require a “shelter in place” are a natural disaster, accidental or intentional release of a chemical, biological or radiological material. If this situation arises, the Incident Command Manager or the Succession Incident Command Manager should:
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Ensure that everyone is moved into the designated shelter room within the clinic that is an interior, windowless room.
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Shut off the HVAC if the incident is a release of chemical, biological and radiological material.
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Encourage everyone “sheltering in place” to contact their emergency contact to let them know their location and that they are safe.
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Have the Emergency Resource Box in the shelter room.
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Initiate the client/family notification protocol and post on various social media that Believe Therapies is sheltering in place and temporarily closed for business.
EMERGENCY PROTOCOLS
DISASTER CODE POSTING
The disaster codes used in the Emergency Protocols will be posted at various points around the clinic in order to provide staff with a visual refence in the event a disaster code is announced. A copy of this posting is attached as Appendix D.
DISASTER PLAN DEFINITIONS
Internal Disaster: Fire or an event that threatens the safety of persons within the clinic and necessitates setting the evacuation plan in order.
External Disaster: Tornado or winter weather storm that necessitates taking cover in the clinic or closing the clinic during regular business hours.
FIRE
POLICY
The primary purpose of the Fire Policy and Procedure is to provide a course of action for all personnel to follow in the event of a fire.
PROCEDURE
The R-A-C-E acronym will assist staff in recalling the procedure on handling a fire.
R - Rescue anyone in immediate danger.
A - Alert other staff members of the fire and location over the intercom system by calling a “Code Red.” Pull the nearest fire alarm. The Incident Command Manager or designee shall contact the fire department by calling 911.
C - Contain the fire. Close all doors to help contain the fire. Shut off all fans and the air conditioners, as these will feed the fire and spread smoke throughout the building.
E - Extinguish if the fire is small.
The P-A-S-S technique for fire extinguisher use:
P - Pull the pin. It is there to prevent accidental discharge.
A - Aim low at the base of the fire. This is the where the fuel source is.
S - Squeeze the lever above the handle. Release to stop the flow.
S - Sweep from side to side. Move toward the fire, aiming low at its base. Sweep until all flames are extinguished. Watch for re-igniting. Repeat as necessary.
Place any fire extinguisher that has been used on its side on the floor. It will be collected after the fire scene is secure. The clinic fire extinguishers are multi-purpose (ABC) extinguishers.
If you cannot extinguish the fire, evacuate the building immediately. Special Note: The most common cause of death in a fire is smoke, and not the flames. Keep low to the floor and avoid inhaling too much smoke.
GENERAL PROCEDURE
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The receptionist will call the fire department at 9-1-1. Give exact location of the fire and its extent.
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Call the Administrator, if not at the clinic.
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Assist with evacuation as necessary.
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The Incident Command Manager or the Succession Incident Command Manager will meet the fire department in order to direct them to the fire and assign a staff member to answer the telephone and relay messages and instructions, if appropriate.
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Upon direction from the Incident Command Manager or the Succession Incident Command Manager, the receptionist can call a “Code Red” over the intercom system or pull the fire alarm to evacuate the building. If the fire is discovered in the back of the clinic any staff member should pull the alert lever so clinic evacuation can occur immediately. It is the responsibility of each employee to know the designated meeting area at each clinic. The staff will calmly escort his/her individual client out of the building by following the posted and closest evacuation route. If clients are separated from their parents/guardians, then the staff will instruct them to exit the nearest safe exit and inform them of the designated meeting place. The child and family should meet at the outside designated meeting area.
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The receptionist or other assigned staff member will keep a roster of clients and on-duty staff and volunteers if evacuation is necessary. To perform the tracking, the receptionist can print a copy of the schedule from the EMR and use that for a check list. The receptionist will verify that everyone has exited the building and report the findings to the Incident Command Manager or the Succession Incident Command Manager.
TORNADO
PURPOSE
The purpose of a Tornado Policy and Procedures is to educate and inform staff of weather conditions that warrant their attention. Believe Therapies wants to keep clients and staff safe at all times. If severe weather strikes, precautions need to be taken to ensure their safety.
DEFINITIONS
Watch -- Means that conditions are favorable for a tornado to develop.
Warning -- Means that a tornado has been sighted. If a siren sounds, stay inside and take cover.
PROCEDURE
If there is a tornado warning,
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Alert other staff members and clients of the tornado warning over the intercom system by calling a “Code Yellow and Announce: "Attention all staff, we are now under a tornado warning, begin severe weather procedures at once." If the intercom does not work, send someone to calmly, alert everyone.
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Make sure everyone is inside. The receptionist or other assigned staff member will keep a roster of clients, on-duty staff and volunteers when sheltering in place. To perform the tracking, the receptionist can print a copy of the schedule from the EMR and use that for a check list. The receptionist will verify that everyone has sheltered and report the findings to the Incident Command Manager or the Succession Incident Command Manager.
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Close all of the doors.
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Gather in the rooms without windows or in the bathrooms.
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Have everyone crouch under a desk or table and/or cover their head. If someone cannot get on the floor or under a table then get extra towels or blankets to cover them and/or their head.
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Gather the Emergency Resource Box to have flashlights or a first kit at hand. Be sure to listen to weather reports for updates. Do not leave the area until the storm has passed and the warning has lifted.
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Stay calm and provide reassurance to the clients. Keep everyone as comfortable as possible.
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The Clinical Administrator or designee will make an individual decision at the time of the event, if notifications need to occur. He/she will decide what types of notifications will also be made on various social media platforms as deemed necessary.
The Receptionist will:
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Repeat announcement.
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Stay at the desk as long as is safe to supervise the front door.
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Send people to the assembly area and close doors in the area.
All Staff:
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Keep calm and reassure and comfort clients and families.
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Advise everyone not to leave the building.
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Provide water to staff and clients and all parties present through the duration of shelter in place.
WINTER STORM SAFETY PRECAUTIONS
PURPOSE
The purpose of these winter storm safety precautions is to inform staff of measures that should be taken during severe winter weather. The following winter storm safety precautions have been established for all personnel to follow during snow, freezing rain, ice storms or sleet.
PROCEDURE
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Don’t panic, remain calm.
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Keep posted on all area weather bulletins and relay to others.
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Keep Emergency Resource Box at the ready.
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Be prepared to evacuate the building, if necessary.
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In an ice/snow event and the roads become impassable, it is the policy of Believe Therapies to follow the school closures within the community. For example, the school district in Huntsville had an ice event and delayed the school opening to 10 am and in Bryan the district cancelled class all day. Therefore, Huntsville can begin to see clients at 10 am and Bryan will cancel and reschedule the visits for that day.
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After making a decision to close the clinic during regular business hours, the Incident Command Manager will then assign the task of notifying the clients/guardians to the receptionist or other staff as necessary.
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The Incident Command Manager or designee can also post this information on various social media platforms to ensure that all clients/guardians are reached.
DOMESTIC DISPUTE
PURPOSE
The purpose of the domestic dispute procedure is to deescalate a situation when tempers can flare.
PROCEDURE
An example of when this may become an issue is with a custody dispute over a child. It is the policy of Believe Therapies to keep court issued documents on who is legally allowed to pick up a minor from therapy. Once the court documents are on file with Believe Therapies, then the receptionist will create “a general alert” in the EMR that will inform the staff about the child’s release restrictions. So, in the example, if mom has legal custody and dad is trying to gain access to the child, tempers may flare in the waiting area. The following procedure should be followed:
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The receptionist should call a “Code Green” over the intercom and immediately alert the Incident Command Manager or the Succession Incident Command Manager to address the situation.
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The Incident Command Manager or the Succession Incident Command Manager should move the angry individual out of the waiting area into a designated, confined area away from other clients.
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The Receptionist or designee should remain close and with a phone in the event 9-1-1 needs to be notified.
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The Incident Command Manager or the Succession Incident Command Manager will attempt to de-escalate the situation and resolve the issue.
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In the event there is no resolution and the situation continues to escalate, the individual will be asked to leave the premises.
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In the event the individual will not leave the premises and the situation continues to escalate, then the receptionist or designee will call 9-1-1 and request police assistance.
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The person calling 9-1-1 is responsible for informing the authorities of the location and nature of the incident.
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After the authorities leave the premise, then the happening should be documented on an incident report form.
PRISON BREAK/ESCAPEE
PURPOSE
The purpose is to ensure safety of staff and clients while at Believe Therapies.
PROCEDURE
In the event of a prison break or escapee situation, staff should do the following:
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The receptionist should call a “Code Green” over the intercom and immediately alert the Incident Command Manager or the Succession Incident Command Manager to address the situation.
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The Incident Command Manager or the Succession Incident Command Manager will immediately lock the doors and inform everyone about the escapee.
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Clients that have an appointment during the lockdown and have not arrived to the clinic, will be called and have their appointment rescheduled to another treatment time.
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Once the Incident Command Manager or the Succession Incident Command Manager is given an all clear by the local authorities, the doors will be unlocked and normal business will resume.
MISSING CHILD
PURPOSE
The purpose is to ensure safety of staff and clients while at Believe Therapies.
PROCEDURE
This is identified as a low risk of happening but because of the nature of the business, is possible to happen.
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Staff, clients and families should follow all established procedures such as:
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Requiring the child to be attended to by the parent at all times while at the clinic. For therapy reasons, the parents/guardians maybe asked to separate from the child, but must remain on premises.
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All children are treated 1:1 ratio with the therapist.
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The staff will hold the hand of a child until the child is returned to the parent.
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Once a child is discovered as missing, the receptionist should call a “Code White” over the intercom and immediately alert the Incident Command Manager or the Succession Incident Command Manager to address the situation.
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Everyone keep calm and let the Incident Command Manager or the Succession Incident Command Manager develop a plan to find the child.
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Staff members will assist as directed by the Incident Command Manager or the Succession Incident Command Manager.
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If the child is not found in a timely manner, 9-1-1 maybe called if necessary.
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After the child is found, the Incident Command Manager or the Succession Incident Command Manager will complete an Incident Report form.
EMERGING COMMUNICABLE DISEASES
PURPOSE
The purpose is to ensure safety of staff and clients while at Believe Therapies.
PROCEDURE
In the event of an emerging communicable diseases, staff should do the following:
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Each clinic should follow the CDC, state and county guidelines for handling the global pandemic.
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Implement Enhanced Infection Control policy and procedures as appropriate to the stated guidelines.
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Continually review staff compliance with Enhanced Infection Control policy and procedures.
TRANSFER OF CASUALTIES AND SHARING OF INFORMATION
Believe Therapies is not equipped to triage clients/families but can begin to prioritize the need for transfer or evacuation of staff/clients/families. Both clinics are across the street from the Emergency Room. But, some situations may require a call for 9-1-1 assistance. The Incident Command Manager or the Succession Incident Command Manager or designee will begin to prioritize the evacuation or transfer using a three level system: Low, Moderate or High Priority and may assign additional staff duties as per the emergency type.
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Low - There is no immediate risk or injury. There is a slight injury and Believe might apply an ice pack to the area or something of the like. No transport needed.
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Medium – There is injury but 9-1-1 does not need to be notified, such as a broken arm. The client and/or family may need assistance to the emergency room (ER) that is across the street from the clinic. If a family member is not present and an escort to the ER is required, then, Believe can print a list of medications and allergies to send with the transfer. The Incident Command Manager or the Succession Incident Command Manager will determine what staff member will provide the transfer.
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High – Anyone can call 9-1-1 and begin CPR or stabilize the person, as much as possible, per the emergency situation. Whoever calls 9-1-1 must go outside and direct the authorities to the location of the emergency and the details about the situation. Believe can print a list of medications and allergies to send with the transfer.
Other staff not involved in the emergency situation should keep calm, comfort other clients and family members and clear the immediate area of the emergency to allow for transport or other emergency personnel to arrive.
Once the emergency situation is resolved, the Incident Command Manager or the Succession Incident Command Manager or designee, whoever was present during the emergency situation, must complete an incident report.
USE OF VOLUNTEERS
Volunteers are not utilized in emergency situations unless specifically directed by an employee during the emergency situation to assist with a simple task. Volunteers are responsible for safe, independent evacuation or for taking cover in a designated room during a tornado. Upon orientation, the volunteer will be given the assigned meeting places for a fire or tornado incident. This will be attached as Appendix F.
RE-ENTRY TO THE CLINIC POST DISASTER
In the event the clinic needs to be evacuated, such as a fire, the Incident Command Manager or Alternate Incident Command Manager is responsible for consultation with the Authorities and making the decision for authorizing re-entry to the building.
INFORMATION, TRAINING, EXERCISE AND PLAN FOR UPDATING THE EMERGENCY MANAGEMENT PLAN
This Emergency Management Plan, training and follow up will be kept in the Minutes Meeting Binder. A copy of just the Emergency Management Plan will be kept in the Emergency Resource Box.
Staff training on the specifics of the Emergency Management Plan will be required of all staff at orientation of new hire and, thereafter, on a minimum of an annual basis during the November Staff meeting. The Emergency Management Plan can be updated as necessary and the Clinical Administrator can schedule a meeting with the Managing Members to review and adopt necessary policy/procedure changes, as needed at any time.
Review of staff training in emergency management will be verified for each staff member during their annual performance review.
At least two Emergency Disaster training exercises will be held on an annual basis for all staff. The Incident Command Manager or the Succession Incident Command Manager will be responsible for planning and critiquing the exercises. After the critique of the exercise, the Client Care Committee will develop a written plan to address noted deficiencies in the annual September meeting. After the annual Client Care Committee meeting in September, the Clinical Administrator will review the EMP with appropriate community officials. Then, the written plan will be verified and approved in the Review of Annual Statistics annual meeting in October. The community is not involved in the exercises at this time because there was no need for this identified on the risk assessment.
After training, staff will be required to take a quiz over the training to demonstrate knowledge of the EMP.
It will be the responsibility of the Clinical Administrator to schedule the Client Care Meeting and the Review of Annual Statistics Meeting with the Managing Members at the beginning of each calendar year. It is the responsibility of the Managing Members, at the beginning of the following month, after said meeting should be been held, to verify that both meetings were held during the scheduled months. If this is found in non-compliance, the Managing Members, will schedule and hold the trainings and meetings and follow the company’s disciplinary policy. The Managing Members will use an electronic calendar notification reminder to assist with tracking the meetings and rescheduling as necessary.
The Emergency Management Plan can be updated as necessary and the Clinical Administrator can schedule a meeting with the Managing Members to review and adopt necessary policy/procedure changes, as needed at any time. In the event there is an update or change in the EMP, the Clinical Administrator will have a training and follow up exercise in the next month’s Staff Meeting, after the adoption of the policy.
APPENDIX DOCUMENTS
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Appendix A – Current Risk Assessment
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Appendix B – Emergency Preparedness Box Inventory List
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Appendix C – Emergency Resource Call List
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Appendix D – Disaster Code Posting
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Appendix E – COVID-19 Policy
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Appendix F – Volunteer Application with Volunteer Fire & Disaster Preparedness Training
CREATED: 10-09-2018
REVISED: 10-20-2020
REGUALATION: 485.727 Condition + Standards (a) - (e)
AAAASF OPT STANDARD: Section 5: In Case of Emergency, Sub-Section D: Emergency Preparedness Plan, Sub-Section E: Emergency Preparedness Plan – Integrated Healthcare System
Believe Therapies
521 I-45 Suite 4,
Huntsville, TX 77340
phone: 936.293.8800
email: info@believetherapies.com
fax: 936.715.3721
Hours
Monday - Friday
8:00AM - 7:00PM

Believe Therapies
2305 Longmire Dr Suite 300
College Station, TX 77845
phone: 936.293.8800
email: info@believetherapies.com
fax: 936.715.3721
Hours
Monday - Friday
8:00AM - 7:00PM