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Canadian Mental Health Association Durham Emergency Preparedness & Business Continuity Plan

June 2015

Revised June 2016

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Contents

1.0 Introduction ........................................................................................................................................... 2

2.0 Purpose of Emergency Preparedness and Business Continuity Plan: ............................................. 2

3.0 Authority................................................................................................................................................ 3

3.1 Organizational Authority ..................................................................................................................... 3

4.0 Incident Management System .............................................................................................................. 3

5.0 Communication ..................................................................................................................................... 4

5.1 Communicating with Staff .................................................................................................................. 4

Fan Out Procedure ............................................................................................................................... 4

5.2 Communicating with Stakeholders & Community Partners ............................................................... 5

Other methods of communication identified ......................................................................................... 6

5.3 Communicating with the Public .......................................................................................................... 6

6.0 Ensuring Continuity of Client Care .................................................................................................... 7

6.1 Assessing Client Needs and Priority Rating ......................................................................................... 7

6.2 Planning for Potential Relocation of Clients ....................................................................................... 7

6.3 Identifying Required Supplies ............................................................................................................. 7

7.0 Alternative Working Arrangements ................................................................................................... 7

8.0 Emergency Codes .................................................................................................................................. 9

Code Red- Fire ...................................................................................................................................... 9

Code Blue- Medical Emergency ........................................................................................................... 9

Code Green- Evacuation ..................................................................................................................... 10

Code Black- Bomb Threat/Suspicious Object ..................................................................................... 11

Code White: Violent/ Behavioral Situation ......................................................................................... 11

Code Orange: External Disaster ........................................................................................................ 12

Code Purple: Hostage Taken/Weapons .............................................................................................. 12

8.1 Emergency and Disaster Drills .......................................................................................................... 13

9.0 Evaluation and Effectiveness ............................................................................................................. 13

10.0 Resources ........................................................................................................................................... 13

Appendix A- Emergency Code Reference Sheet .................................................................................. 14

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EMERGENCY PREPAREDNESS AND BUSINESS CONTINUITY PLAN

1.0 Introduction Definition of Emergency:

An emergency is defined as a sudden, urgent and usually unexpected occurrence or occasion caused by

the forces of nature, an accident, and intentional act or otherwise that constitutes a significant danger

to life or property thus requiring immediate attention.

2.0 Purpose of Emergency Preparedness and Business Continuity Plan: The Canadian Mental Health Association Durham Emergency Preparedness and Business Continuity Plan

provides a framework to ensure the most efficient continuance of services and describes the procedures

for handling unexpected situations that require immediate attention in the event of an emergency. By

taking a proactive approach towards Emergency Preparedness and Business Continuity, the organization

is better able to anticipate and plan for untoward events that could place staff, clients and visitors at

risk.

In addition to the Emergency Preparedness and Business Continuity Plan, the Canadian Mental Health

Association Durham has a separate Pandemic Plan. Pandemics occur when a new viral strain emerges,

the new virus, which the population has little or no immunity to, can spread efficiently from human to

human and may cause serious illness and/or death. The Canadian Mental Health Association Durham

Pandemic Plan describes how the organization will respond to a pandemic and sets out a comprehensive

approach to health preparedness and response planning. The Pandemic Plan provides information to

guide planning groups within the organization.

The purpose of the Emergency Preparedness and Business Continuity Plan is to assist employees, clients,

family/caregivers and community partners in dealing with situations that may occur as a result of the

following situations:

Category A – Non life-threatening situation that would prevent any number of employees from

accessing the workplace or from remaining in the workplace. This situation would likely be for a

short period of time (i.e. several hours). Examples are:

o Problem with plumbing in the building, no running water, flooding

o No power in the building

o Problem with the heating system

o Fumes

o Snowstorm/Inclement weather

o Emergency Code1

Category B – Non life-threatening situations having a city-wide or regional impact. Examples

are:

1 Canadian Mental Health Association Durham Health and Safety Policy and Procedure HS 2a Standardized Emergency Codes.

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o Ice storm/Inclement weather

o Power shortages

o Floods

o General Infrastructure shutdown (i.e. bus strike)

o Emergency Code

Category C – Potential life-threatening situations or property damage. Example are:

o Floods

o Fires

o Ice storms

o Earthquakes

o Tornadoes

o Hurricanes

o Terrorist Attack

o General Public Health (communicable disease, pandemic)

o Emergency Code

o Nuclear Disaster

3.0 Authority “The City of Oshawa is responsible for the implementation of emergency measures to protect the

population, property and environment with the City.”2

The head of council of a municipality may declare that an emergency exists in the municipality or in any

part thereof and may take such action and make such orders as he or she considers necessary and are

not contrary to law to implement the emergency plan of the municipality and to protect property and

the health, safety and welfare of the inhabitants of the emergency area. R.S.O. 1990, c. E.9, s. 4 (1).

The applicable legislation requires that all municipalities establish and maintain Emergency

Management Programs. Currently the Canadian Mental Health Association Durham is not linked and

assigned with duties and responsibilities as a community partner in the Durham Region.

3.1 Organizational Authority The following individuals occupying the identified positions may officially authorize staff members to

activate the plan:

The Chief Executive Officer, or designate

The Director of Corporate Services, or designate.

The Chief Executive Officer, the Director of Corporate Services, or designate may identify an

Emergency Coordinator depending on the nature and the location of the emergency.

4.0 Incident Management System The Canadian Mental Health Association Durham, under the Authority of the Chief Executive Officer, or designate, will initiate and execute the organizations Emergency Preparedness and Business Continuity

2 City of Oshawa, Emergency Master Plan, May 2006, revised September, 2010

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Plan and execute the organizations Fan Out procedure. The Incident Management System structure consists of an incident commander who assumes responsibility for operations planning and logistics and a task force to implement the plan and accomplish the task objectives.

5.0 Communication

5.1 Communicating with Staff

Fan Out Procedure The Fan Out procedure is used to notify all staff that a “State of Emergency” has been declared and

provides staff with the status for reporting to work.

1. The Chief Executive Officer will initiate the Fan Out by contacting the Director of Corporate

Services, Director of Programs and Clinical Services and the Coordinator for Clinical Programs and

Services3. All staff will be contacted as per the Fan Out Chart (Diagram 1).

2. The Director/Coordinator of Programs and Clinical Services will contact all Team Leads4 to advise

them of the State of Emergency. The Director/Coordinator of Programs and Clinical Services will

make arrangements to contact contracted in house services i.e. Durham Region Employment

Network, on-site Pharmacy.

3. Team Leads will contact all staff within their program area via email, BBM or text message.

Employees that are not issued an organizational mobile device will be contacted by other means;

home telephone, personal cell, next of kin.

4. All employees will confirm receipt of message with their Team Lead/Coordinator.

5. Team Leads/Coordinators will cross reference employee confirmation of notification to a current

employee roster to ensure that all staff have been apprised of the “state of emergency” and

provided with direction.

6. Team Leads and Coordinators will report back to the Director of Programs and Clinical Services

with the status of their respective staff.

7. The Director of Programs and Clinical Services will report the findings to the Chief Executive

Officer.

The Canadian Mental Health Association Durham employee roster is available for all management at

http://cmhadurham.ca/. The employee roster is maintained and managed by the Canadian Mental

Health Association Durham, Human Resources Department. The Human Resources Department will

provide the Team Leads, Coordinators, and Senior Management with a monthly electronic copy of the

employee roster and contact numbers. It is the responsibility of Team Leads, Coordinators, and Senior

Management to ensure that a hard copy of the employee roster is available/accessible in the event of an

emergency.

3 In the event that an individual(s) is absent from their duties, the appointed designate acting on their behalf will be contacted. 4 Team Lead includes the Nurse Practitioner Led Clinic Lead Nurse Practitioner, Nurse Practitioner Led Clinic Administrator and IT.

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Diagram 1

5.2 Communicating with Stakeholders & Community Partners

Chief Executive Officer contacts the

Chair of the Board of Directors

Director of Corporate

Services contacts IT re:

Communication Service

Providers

Health Promotions/Media

Relations Specialist

contacts media (as

required)

Team Lead of FPMD

contacts Security,

Cleaners, Contractors, and

Service Technicians (i.e.:

elevator)

Coordinator for Clinical

Programs and Services

contacts Community

Partners as required

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Other methods of communication identified

Canadian Mental Health Association Durham website - All staff have access to the website

including the staff portal which will provide additional information on the state of emergency

and any required actions/procedures. The use of the website will be dependent on the

availability of CMHA Durham server and internet services during a state of emergency;

Home phone or personal cell;

Staff call-in to central voice mail for updates;

Safety Box at the front entrance which contains the Emergency Preparedness and Business

Continuity Plan, Fire Safety Plan, First Aid Kit, Flashlights/batteries and Emergency After Hours

Building Contact Numbers (3rd party contracted services).

The Canadian Mental Health Association Durham utilizes a variety of technologies in its day to day

operations. In order to prevent the loss of data due to unforeseen circumstances such as disasters and

emergencies, the organization ensures that steps are taken to prevent or mitigate such loss related to

IT/server failure. The organizations electronic mail, electronic medical records and electronic financial

records are cloud based technology. Therefore, these records are managed and maintained off site by

the software vendor (i.e. Microsoft, EMHware, and Nightingale). All other hardware maintained by the

Canadian Mental Health Association Durham is backed up daily (internally and externally) to an

authorized and secured off-site location.

5.3 Communicating with the Public

Signage

In the event of closure, signage will be posted on the front entrance doors of 60 Bond Street West.

Signage will read as follows:

“Our office is currently closed due to _____________ (state emergency). If this is an emergency, please

call mobile crisis at 905-666-0483 or call 911. Canadian Mental Health Association Durham staff please

access the Canadian Mental Health Association Durham website through the staff portal for further

direction. ”

Voice Mail Message:5

“Hello, you have reached Canadian Mental Health Association Durham. Our office is currently closed due

to _____________ (state emergency). If this is an emergency, please call mobile crisis at 905-666-0483

or call 911. If you know the extension of the person you are trying to reach, press pound 8 and the

extension number now or leave a message after the tone.”

5 NPLC will ensure clinic voicemail is reflective to that of the Canadian Mental Health Association Durham’s main

reception voicemail.

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6.0 Ensuring Continuity of Client Care

6.1 Assessing Client Needs In preparation for a potential emergency, client care needs must be assessed so that appropriate

supports can be provided during an emergency. This will ensure that limited staff resources can focus on

clients with priority needs. Programs must identify clients who will be a priority in the event of an

emergency. A Crisis Information Sheet is used for each client and includes a priority rating ranging from

1 (high) to 3 (low) to identify clients with higher needs and therefore, a priority for support during an

emergency.

Level 1 = client lacks natural supports of any kind outside of their Canadian Mental Health Association

Durham treatment team. These clients require regular medication observation due to consistent non-

compliance. These clients are usually seen by the team daily.

Level 2 = client has some natural support outside of their Canadian Mental Health Association Durham

treatment team (i.e.) social ties within their housing, family that visits occasionally, etc. Priority 2 clients

may struggle with medication compliance on occasion, and do not manage their own medications.

Priority 2 clients are seen by the team 3-4 days per week on average.

Level 3 = these clients maintain their medications independently, and have natural supports outside of

their Canadian Mental Health Association Durham treatment team. Priority 3 clients are seen by the

team 1-2 days per week on average.

All Crisis Information Sheets will be reviewed every 6 months or as needed, to assess the priority rating

given and aligns with the Pandemic Plan for the coordination of essential services.

6.2 Planning for Potential Relocation of Clients Clients may need to be moved out of Canadian Mental Health Association Durham housing to reduce

their risk in an emergency. Clients have been asked to indicate whether they have relatives or friends

with whom they can stay with in an emergency situation.

6.3 Identifying Required Supplies In the event of an emergency, basic supplies (food, water, first aid, and personal protective equipment)

will be collected instead of stored indefinitely due to expiry dates. Frontline staff carry first aid kits in

their personal vehicles. Canadian Mental Health Association Durham’s supportive housing locations

retain emergency supplies and replenish them regularly.

7.0 Alternative Working Arrangements In the event that any of the above situations results in a temporary office closure, department heads

should be encouraging their employees to pursue alternative working arrangements (i.e. workings off-

site to the best of their ability). Department heads, again where possible, are expected to contact their

employees to discuss what arrangements may be made for off-site meetings, the drawing up of lists of

priority actions, and how best to remain in touch and up to date on the activities of their team/program.

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Those employees with remote access through VPN (virtual private network) and/or mobile devices (i.e.

iPads, iPhones, Blackberries) should be expected to work from home or an alternate location.

While the situation regarding the re-opening of office will be re-assessed daily, department heads are

encouraged to review their agendas and work-plans to consider, should access to their work place

continue not to be possible, what issues and projects urgently need to be dealt with and what work can

be most easily completed by employees working off-site. Department heads should contact their staff,

and where appropriate or necessary, make arrangements to meet and/or stay in contact by phone or e-

mail.

Employees should be encouraged to regularly check their voice-mail for their office extension as well as

for their mobile devices. Employees should be encouraged to modify their recorded greetings to reflect

the current status of operations as it pertains to the closure and the continuance of business.

Maintenance of pay for employees who are unable to report to work due to office closures

All employees who are unable to report to work due to office closures should continue to be paid for

their regularly scheduled hours of work during the period of these office closures.

Employees in acting situations at the time of the office closures should continue to be paid at their

acting level.

Leave for employees during an office closure

Employees are not required to submit leave forms for periods where the Chief Executive Officer has

suspended normal business operations.

Approved leave is not to be displaced. Where leave (i.e. annual, sick, family related, without pay) was

previously authorized, employees would not have been planning on reporting to work and would

therefore not have been affected by the office closure.

Leave for employees directly affected by an emergency situation while office is open

Department heads have the flexibility and discretion to grant a leave of absence or alternative work

arrangement to employees directly affected by an emergency situation. Where an employee or their

families are personally affected by the event, they are encouraged to communicate with their manager

to review their individual circumstances and any reasons preventing them for reporting for work. The

decision to grant/not grant leaves is one best determined by the manager who knows the operational

requirements of the program area.

Those employees involved in providing emergency relief services (i.e. volunteer fire, armed forces

reserve) should in most circumstances be granted leave with pay. Those employees wishing to work in

emergency shelters should be required to obtain prior approval from a department head, and the extent

possible, these employees should maintain regular (daily) contact with their immediate supervisors. The

decision to grant/not grant leave is one best determined by the department head who knows the

operational requirements of the work area and the emergency situation in respect of the employee

requesting leave.

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Once normal business operations have resumed, leave forms must be completed for all absences that

have been verbally authorized by managers.

8.0 Emergency Codes The Canadian Mental Health Association Durham has established a standard set of color coded calls for

emergency communications to be used via Public Address System and other communication means. The

codes provide a concise means of ensuring staff receive a common message, signaling the need for an

urgent response without unnecessarily alerting or alarming clients, and or visitors. The use of a uniform

color coded system will assist in ensuring that the appropriate staff responds to the potential

emergency.

Codes: Standardized Emergency6

INCIDENT CODE

Fire Code Red

Medical Emergency Code Blue

Evacuation Code Green

Bomb Threat/Suspicious Object Code Black

Violent /Behavioral Situation Code White

External Disaster Code Orange

Hostage Taking/Weapons Code Purple

Code Red- Fire

Note: Please review HS 3a Fire Safety, Drills, & Evacuation Policy and Procedure for detailed Instructions Upon discovery of a fire, you should (RACE):

1. Remove endangered persons 2. Activate the fire alarm

- Proceed to nearest pull station, pull to activate - If no fire pull station available- staff to yell “FIRE”, call Reception to page a “CODE

RED” 3. Contain the fire

- Close all windows, door, and other openings 4. Evacuate

- Immediately leave the area as directed and proceed to the designated meeting location and call 911 when you are in an area of safety. Await notification from the Canadian Mental Health Association’s Chief Fire Warden and the Fire Department

Code Blue- Medical Emergency

Any personnel who find an individual in apparent injury may initiate a Code Blue to assure the prompt

and skilled resuscitation and/or medical intervention. This may include any of the following:

A = Airway

B = Breathing

C = Circulation

6 Adapted from OHA Standardized Emergency Colour Codes

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Or any of the following:

- Seizure - Severe bleeding and wounds - Burns - Electric shock

First Responder Staff must stay with the individual and summon help by whatever means are available.

In order to summon the Code Blue:

1. First Responder Staff must identify the Emergency correctly. 2. First Responder Staff then immediately designates someone to (a) Notify Reception of the Code

name (refer to Emergency procedure chart) and Code Location AND (b) to call 9-1-1 to report Emergency.

3. Trained staff will respond to the Code (1-2 persons/floor). 4. Staff will obtain the Automated External Defibrillator (AED). AED’s are located on the 1st, 4th, 5th

and 7th floors. 5. First Responder Staff must remain with the client until 9-1-1 staff arrives on scene. 6. First Responder Staff should designate a third party to take notes (recorder) about the

Emergency including blood pressure, pulse, temperature that are performed until 9-1-1 staff arrives.

7. If possible, First Responder Staff should also designate another staff member to obtain client’s Crisis sheet and UPDATED Medication Administration Record (MAR)

8. If possible, the staff member most familiar with the client will stay with client until 9-1-1 staff arrives.

9. The First Responder Staff must initiate an incident report immediately after the Emergency.

Code Green- Evacuation

Code Green is called when a general emergency evacuation or relocation is required due to safety concerns within the facility. Evacuation steps:

1. notify reception (101) to initiate a Code Green (identify location, emergency, relocation area) 2. paging emergency internally *3301 to initiate a code, if Reception not available 3. close all doors and evacuate to the designated meeting location 4. do not return to the building/area until notification is given by the Manager of Facilities or

designate If the paging system is unavailable (power outage), a Code Green will be initiated by the Manager of Facilities or designate completing a floor sweep or by activating the Fire Alarm depending on the emergency. During a prolonged evacuation, “Fan-Out” procedures and alternate working arrangements may be initiated.7

7 “Fan-Out” procedures detailed in The Canadian Mental Health Association Durham’s’ Emergency Preparedness and Business Continuity Plan

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Code Black- Bomb Threat/Suspicious Object

A Code Black is called when there is reasonable concern and/or threat has been received and or a suspected explosive device located. The individual receiving the bomb threat (and/or supervisor reporting it) should immediately notify the Manager of Facilities, or designate, who will then notify the Chief Executive Officer and Directors. Bomb Threat Steps:

1. Call 911 to report and tell them all you can about the threat 2. Notify your supervisor and the Manager of Facilities or designate 3. If advised by emergency personnel to evacuate, call Code Green 4. When emergency personnel arrive, advise them of the threat and assist as requested

Suspicious Object:

1. Do not touch, move, or open it 2. Evacuate the immediate area 3. Call 911 to report and tell them all you can about the object 4. Isolate the area as much as possible 5. Do not close doors unless determined absolutely necessary for security 6. Keep people out of the area 7. If advised by emergency personnel to evacuate, call Code Green 8. When emergency personnel arrive, advise them of the object location and assist as requested

Code White: Violent/ Behavioral Situation

Call a Code White when you witness or are involved with any individual who is not responding to de-escalation intervention and is:

1. Threatening, harassing, or behaving verbally abusive to you or another individual 2. Attempting to harm themselves or others 3. Attempting to destroy property 4. Displaying threatening behavior that is escalating 5. Refusing to leave Canadian Mental Health Association Durham property when requested

Code White Steps:

1. Remove yourself and others from immediate danger 2. Call reception (101) to initiate a code OR page internally *3301 if Reception not available 3. call to 911, as appropriate

Should the incident occur at Reception staff will initiate the panic alarm which sounds throughout the building. Staff should respond to the panic alarm in the same manner as a Code White. Responding staff members to complete the following:

1. Address the individual 2. Provide assistance and direct staff, including the responding staff from other programs 3. Await the need to call 911 and direct emergency personnel to location of incident

Important Notice: Remember to clear environmental hazards (these could be used potentially as weapons) from the area. Remember to use the stairway to escort an individual that is being asked to leave

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Code Orange: External Disaster

This Emergency Code is called when a Disaster in the Community is imminent.

CODE Description

Code Orange Advisory Conditions are present which increase the possibility that a disaster could occur in the community (i.e. terrorist threat)

All staff must wear their ID Badge

Code Orange Alert CMHA has been notified that a disaster has occurred in the community and is awaiting direction from community advisors.

No reports of injuries have been confirmed at this time

Code Orange Confirmed Hospitals in the community are receiving patients with injuries.

Depending on the nature of external disaster, The Canadian Mental Health Association Durham will

follow the Pandemic Preparedness and Response Plan and/or the Emergency Preparedness and Business

Continuity Plan accordingly.

In the unlikely event of a serious nuclear accident where a radioactive release would occur, The

Canadian Mental Health Association Durham would follow the directives of the municipal government’s

emergency management office. 8

Code Purple: Hostage Taken/Weapons

A code purple is to be called in the event of a situation where any person is confined forcibly, seized or detained against their will, with the threat of a weapon or threat of violence OR Where an individual has possession of a weapon and is threatening violence to themselves or others. Code Purple Steps:

1. Ensure safety of staff, client, and visitors in the immediate area, if there is any sign of actual danger or violence to any person, DO NOT attempt any action. Staff should not place themselves at risk and are to contain the incident only until assistance arrives.

2. Call 911 and provide as much information as possible 3. Dial 101 and advise Reception of the situation, Reception NOT to page an overhead code unless

given direction to do so by the Police. 4. Reception to call each floor to advise of the situation that all staff, clients and visitors get into a

safe and secure location (close and lock doors and blinds). 5. Do not initiate conversation with the hostage taker(s) but do answer if spoken to. Try to

establish a rapport with the hostage taker(s). Wait for Police to arrive.

8 OPG Nuclear Safety Guide, http://www.opg.com/about/safety/emergency-preparedness/Documents/NuclearSafetyGuide.pdf

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8.1 Emergency and Disaster Drills The Canadian Mental Health Association conducts various organizational drills throughout the year to ensure staff and clients are familiar with the process of an emergency evacuation.

DRILL (TYPE) FREQUENCY

Emergency Codes Annually

Evacuation Annually (minimum) per shift

Fan-out Annually

Emergency exit routes and meeting spot information is posted on each stairwell door of 60 Bond Street West. In the event of an emergency evacuation, staff and clients shall meet at the northwest corner of the 60 Bond Street West. In the event of an emergency and evacuation is needed all staff shall evacuate the building as per evacuation procedures and await instructions from the organizations leaders. If deemed necessary closure of the building will be in effect and appropriate emergency personnel and building technicians dispatched.

9.0 Evaluation and Effectiveness Emergency evacuation drills shall be conducted bi-annually at various times to ensure that all staff, Board Members, clients and visitors are aware of the procedure. Results of these drills shall be documented accordingly by the organization detailing the emergency situation, details of the evacuation and procedures followed and any follow-up needed.

A post evaluation meeting is held to review the effectiveness of the specified drill. At time of review,

the effectiveness of the drill and potential for improvements will be determined and recommendations

shall be submitted for approval and implementation if warranted.

The Emergency Preparedness and Business Continuity Plan shall be reviewed annually by the

organizations Leaders. A Risk Assessment shall be completed to identify potential disasters and

emergencies which the organization may encounter as well as to determine the likelihood of an event,

the impact on the organization, the adequacy of controls to mitigate the risk of a disaster or emergency.

The Risk Assessment analysis results in information that provides a foundation for mitigation activities.

10.0 Resources All plans, strategies, and policy and procedures referenced in this document can be accessed through

the attached links:

Internal: Canadian Mental Health Association Durham

Z:\Plans and Strategies\Fire Safety Plan Updated January 2016.pdf

Z:\Plans and Strategies\Risk Management Plan 2015.pdf

Z:\Plans and Strategies\Pandemic Plan February 2016.pdf

External: Durham Region

http://www.durham.ca/departments/demo/emerplan.pdf

http://www.durham.ca/default.asp?nr=/departments/demo/demoinside.htm

http://www.oshawa.ca/residents/resources/emergencymasterplan.pdf

Appendix A- Emergency Code Reference Sheet

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Code Red Fire

Upon discovery of a fire, you should (RACE): 1. Remove endangered persons 2. Activate the fire alarm

- Proceed to nearest pull station, pull to activate - If no fire pull station available- staff to yell “FIRE”, call Reception to page a “CODE RED”

3. Contain the fire - Close all windows, door, and other openings

4. Evacuate - Immediately leave the area as directed and proceed to the designated meeting location and call 911 when you are in

an area of safety. Await notification from CMHA’s Chief Fire Warden and the Fire Department

Code Blue Medical

Emergency

In order to summon the Code Blue: 1. First Responder Staff must identify the Emergency correctly 2. First Responder Staff then immediately designates someone to (a) notify reception of the code and code location AND (b) to call 9-

1-1 to report emergency 3. Trained staff will respond to the code (1-2 persons/floor) 4. Staff will obtain an Automated External Defibrillator (AED) which are located on the 1

st, 4

th, 5

th and 7

th floors

5. First Responder Staff must remain with the client until 9-1-1 staff arrives on scene 6. First Responder Staff should designate a third party to take notes (recorder) about the emergency including blood pressure, pulse,

temperature that are performed until 9-1-1 staff arrives 7. If possible, First Responder Staff should also designate another staff member to obtain client’s crisis sheet and UPDATED

Medication Administration Record (MAR) 8. If possible, the staff member most familiar with the client will stay with client until 9-1-1 staff arrives 9. The First Responder Staff must initiate an incident report immediately after the emergency

Code Green Evacuation

Evacuation steps: 1. Notify reception (101) to initiate a Code Green (identify location, emergency, relocation area) 2. Paging emergency internally *3301 to initiate a code, if Reception not available 3. Close all doors and evacuate to the designated meeting location 4. Do not return to the building/area until notification is given by the Manager of Facilities or designate

Code Black Bomb Threat/

Suspicious Object

Bomb Threat Steps: 1. Call 911 to report and tell them all you can about the threat 2. Notify your supervisor and the Manager of Facilities or designate 3. If advised by emergency personnel to evacuate, call Code Green 4. When emergency personnel arrive, advise them of the threat and assist as requested Suspicious Object: 1. Do not touch, move, or open it 2. Evacuate the immediate area 3. Call 911 to report and tell them all you can about the object 4. Isolate the area as much as possible 5. Do not close doors unless determined absolutely necessary for security 6. Keep people out of the area 7. If advised by emergency personnel to evacuate, call Code Green 8. When emergency personnel arrive, advise them of the object location and assist as requested

Code White Violent/

Behavioral Situation

Code White Steps: 1. Remove yourself and others from immediate danger 2. Call reception (101) to initiate a code OR page internally *3301 if Reception not available 3. call to 911, as appropriate

Code Orange External Disaster

Depending on the nature of external disaster, The Canadian Mental Health Association Durham will follow the Pandemic Preparedness and Response Plan and/or the Emergency Preparedness and Business Continuity Plan accordingly. In the unlikely event of a serious nuclear accident where a radioactive release would occur, The Canadian Mental Health Association Durham would follow the directives of the municipal government’s emergency management office.

Code Purple: Hostage Taken/

Weapons

Code Purple Steps: 1. Ensure safety of staff, client, and visitors in the immediate area, if there is any sign of actual danger or violence to any person, DO

NOT attempt any action. Staff should not place themselves at risk and are to contain the incident only until assistance arrives. 2. Call 911 and provide as much information as possible. 3. Dial 101 and advise Reception of the situation, Reception NOT to page an overhead code unless given direction to do so by the

Police. 4. Reception to call each floor to advise of the situation that all staff, clients and visitors get into a safe and secure location (close and

lock doors and blinds). 5. Do not initiate conversation with the hostage taker(s) but do answer if spoken to. Try to establish a rapport with the hostage

taker(s). Wait for Police to arrive.