Disaster Planning

Handbook for
Behavioral Health
Treatment Programs

Technical Assistance Publication Series

TAP 34

Disaster Planning Handbook

for Behavioral Health
Treatment Programs

TAP
Technical Assistance Publication Series

34

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment

1 Choke Cherry Road

Rockville, MD 20857
Disaster Planning Handbook for Behavioral Health Treatment Programs

Acknowledgments Electronic Access and Copies

This publication was prepared for the of Publication
Substance Abuse and Mental Health Services This publication may be ordered or
Administration (SAMHSA) by the Knowledge downloaded from SAMHSA’s Publications
Application Program, a Joint Venture of The Ordering Web page at http://store.samhsa.gov.
CDM Group, Inc., and JBS International, Or, please call SAMHSA at 1-877-SAMHSA-7
Inc., under contract number 270-09-0307, (1-877-726-4727) (English and Español).
with SAMHSA, U.S. Department of Health
and Human Services (HHS). Christina
Currier served as the Contracting Officer’s
Representative. Recommended Citation
Substance Abuse and Mental Health Services
Administration. Disaster Planning Handbook
Disclaimer for Behavioral Health Treatment Programs.
Technical Assistance Publication (TAP) Series
The views, opinions, and content of this 34. HHS Publication No. (SMA) 13-4779.
publication are those of the authors and do Rockville, MD: Substance Abuse and Mental
not necessarily reflect the views, opinions, or Health Services Administration, 2013.
policies of SAMHSA or HHS.

Originating Office
Public Domain Notice
Quality Improvement and Workforce
All materials appearing in this document Development Branch, Division of Services
except those taken from copyrighted Improvement, Center for Substance Abuse
sources are in the public domain and may Treatment, Substance Abuse and Mental
be reproduced or copied without permission Health Services Administration, 1 Choke
from SAMHSA or the authors. Citation Cherry Road, Rockville, MD 20857.
of the source is appreciated. However,
this publication may not be reproduced or HHS Publication No. (SMA) 13-4779
distributed for a fee without the specific, Printed 2013
written authorization of the Office of
Communications, SAMHSA, HHS.

ii
Contents

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

Audience for This TAP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

Organization of This TAP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiv

Behavioral Health Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiv

Disaster Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv

Chapter 1—Rationale and Process for Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Essential Partners in National Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Providers of Essential Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Partners in Community Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Mandates for Disaster Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

All-Hazards Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

The Planning Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Continuity Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Overview of the Written Disaster Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Drafting a Usable Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Chapter 2—Beginning the Disaster Planning Process . . . . . . . . . . . . . . . . . . . . . . . 9

Select a Disaster Planning Team Leader and Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Obtain Support From the Organization’s Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Review Requirements for Disaster Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Coordinate Planning With Others . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Educate the Community About Behavioral Health Services . . . . . . . . . . . . . . . . . . . . . . 21

Prepare a Hazard Identification and Risk Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Specify Planning Objectives and Assumptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

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Disaster Planning Handbook for Behavioral Health Treatment Programs

Chapter 3—Preparing for Disaster . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Mitigate Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Negotiate Memoranda of Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Designate Personnel To Assume Command for Incident Response . . . . . . . . . . . . . . . . . 31

Prepare Clients for a Disaster . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Obtain Client Locator Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Encourage Staff To Make Plans for Personal Preparedness . . . . . . . . . . . . . . . . . . . . . . . 35

Prepare Staff for Supporting Clients in Disaster. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Prepare To Connect Clients to Disaster Case Management . . . . . . . . . . . . . . . . . . . . . . . 40

Ensure Counselor Access to Shelters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Prepare for Financial Resiliency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Chapter 4—Continuity Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Identify Essential Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Identify Essential Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Provide for Continuity of Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Arrange for Alternate Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Ensure Interoperable Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Protect Vital Records and Databases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Develop Resources To Manage Human Capital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Chapter 5—Management of Prescription Medications . . . . . . . . . . . . . . . . . . . . . . 57

Give Careful Oversight to Clients on Prescription Medications . . . . . . . . . . . . . . . . . . . . 57

Help Clients Access Prescription Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Provide for Continued Methadone Dosing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Prepare for Transfers of Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Treat the Guest Patient on Methadone Maintenance Treatment. . . . . . . . . . . . . . . . . . . 60

Handle an Influx of Patients With Opioid Dependence. . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Address the Needs of Displaced Patients on Buprenorphine . . . . . . . . . . . . . . . . . . . . . . 61

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 Contents

Refer or Treat Pain Patients, as Appropriate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Manage Supplies of Controlled Substances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Chapter 6—Planning Issues for Pandemic Influenza . . . . . . . . . . . . . . . . . . . . . . . 65

Potential Effects of Pandemic Influenza. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Procedures To Reduce Influenza Transmission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Vaccines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

Antiviral Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

Hygiene Policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Staffing Policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Staff Attitudes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

Planning Assumptions for Pandemic Influenza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

Drafting and Activating the Pandemic Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

Chapter 7—Completing, Testing, Activating, and Deactivating the Plan . . . . . 73

Assemble the Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Distribute the Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

Train and Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

Activate the Plan in Disaster . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Deactivate and Revise the Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

Coordinate With the Community in Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

Support Staff Members, Clients, and Community After the Disaster . . . . . . . . . . . . . . . 80

Continuously Revise and Update the Disaster Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

Appendix A—Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

Appendix B—Worksheets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Worksheet B1 Checklist for the Written Disaster Plan . . . . . . . . . . . . . . . . . . . . . . . . . . 90

Worksheet B2 Checklist for Disaster Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

Worksheet B3 Checklist of State and Community Representatives and Groups . . . . . . 93

Worksheet B4 Checklist of Disaster Planning Discussion Topics. . . . . . . . . . . . . . . . . . . 94

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Disaster Planning Handbook for Behavioral Health Treatment Programs

Worksheet B5 Sheltering-in-Place Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

Worksheet B6 Record of Memoranda of Agreement and Qualified Service

Organization Agreements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Worksheet B7 Incident Command System Positions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

Worksheet B8 Identify Essential Functions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

Worksheet B9 Identify Essential Staff Positions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100

Worksheet B10 Essential Staff Roster . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

Worksheet B11 Checklist for Continuity Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

Worksheet B12 Requirements for Alternate Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . 106

Worksheet B13 Alternate Facility Arrangements by Disaster Scenario . . . . . . . . . . . . 107

Worksheet B14 Checklist for Relocation Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

Worksheet B15 Checklist for Maintaining Communications With Essential

Groups. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

Worksheet B16 Checklist of Records and Databases To Ensure Interoperable

Communications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

Worksheet B17 Checklist for Protecting Records and Databases . . . . . . . . . . . . . . . . . . 112

Worksheet B18 Checklist for Managing Human Capital . . . . . . . . . . . . . . . . . . . . . . . . 113

Worksheet B19 Checklist for Management of Prescribed Medications . . . . . . . . . . . . . 115

Worksheet B20 Disaster Plan Training and Testing Log . . . . . . . . . . . . . . . . . . . . . . . . 117

Appendix C—Abbreviations and Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

Appendix D—Disaster Planning Web Resources . . . . . . . . . . . . . . . . . . . . . . . . . . 121

Appendix E—WATrac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127

Appendix F—Sample Memorandum of Agreement Between Opioid

Treatment Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129

Appendix G—Editorial Board and Field Reviewers . . . . . . . . . . . . . . . . . . . . . . . 135

Appendix H—Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

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Exhibits

Exhibit 2-1. Importance of Comprehensive Training for All Staff . . . . . . . . . . . . . . . . . . 10

Exhibit 2-2. Mobilization of Behavioral Health Responders To Assist

Hurricane Evacuees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Exhibit 2-3. Mobilization of Behavioral Health Responders To Assist

Earthquake Emergency Responders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Exhibit 2-4. Discriminatory Attitudes That Affected Care for People With

Mental Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Exhibit 2-5. Discriminatory Attitudes That Affected Care for People With

Substance Use Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Exhibit 2-6. Networking To Improve Readiness for Disaster (Example 1) . . . . . . . . . . . 14

Exhibit 2-7. Networking To Improve Readiness for Disaster (Example 2) . . . . . . . . . . . 14

Exhibit 2-8. Program Use of SERG Grants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Exhibit 2-9. Distribution of Financial Aid in Louisiana After Hurricanes

Katrina and Rita . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Exhibit 2-10. Collaborative Planning by Healthcare Organizations . . . . . . . . . . . . . . . . 17

Exhibit 2-11. Sample of a Disaster-Specific Prevention Message . . . . . . . . . . . . . . . . . . . 21

Exhibit 2-12. Example of Need To Coordinate With Voluntary Organizations . . . . . . . . 22

Exhibit 2-13. Examples of Program Vulnerabilities and Strengths in a

Disaster. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Exhibit 3-1. Welcome Bags and Personal Go Kits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Exhibit 3-2. Preparing for Power Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Exhibit 3-3. Examples of Disaster Mitigation Specific to a Behavioral Health

Treatment Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Exhibit 3-4. Negotiation for Assistance in Hurricane Season . . . . . . . . . . . . . . . . . . . . . . 29

Exhibit 3-5. Negotiation for Mutual Aid Following a Major Snowfall . . . . . . . . . . . . . . . 29

Exhibit 3-6. Staff Issues To Consider in Mutual Aid Agreements . . . . . . . . . . . . . . . . . . 30

Exhibit 3-7. Incident Command System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

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Disaster Planning Handbook for Behavioral Health Treatment Programs

Exhibit 3-8. Hypothetical Example of an ICS in Action . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Exhibit 3-9. Psychological First Aid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Exhibit 3-10. Challenges in Disaster Preparedness for Clients With Limited

English Proficiency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Exhibit 4-1. Examples of Essential and Nonessential Functions . . . . . . . . . . . . . . . . . . . 44

Exhibit 4-2. Essential Operations Continuity During a Winter Storm

(Example 1). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Exhibit 4-3. Essential Operations Continuity During a Winter Storm

(Example 2). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Exhibit 4-4. Examples of Order of Succession at a Behavioral Health

Treatment Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Exhibit 4-5. Communication Tree . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Exhibit 4-6. Priority Communications in an Emergency. . . . . . . . . . . . . . . . . . . . . . . . . . 50

Exhibit 4-7. Benefits of Electronic Health Records (Example 1). . . . . . . . . . . . . . . . . . . . 52

Exhibit 4-8. Benefits of Electronic Health Records (Example 2). . . . . . . . . . . . . . . . . . . . 52

Exhibit 4-9. Office for Civil Rights HIPAA Guidance Following Hurricane

Katrina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Exhibit 4-10. Building Staff Willingness To Respond in Disaster . . . . . . . . . . . . . . . . . . 55

Exhibit 5-1. Distant Dispersal of OTP Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Exhibit 5-2. An OTP’s Continuity Plan Executed Before Hurricane Hugo . . . . . . . . . . . 61

Exhibit 5-3. Guidance for Treating OTP Patients From Areas Affected by

Emergency Closure of Programs in the Event of a Disaster . . . . . . . . . . . . . . . . . . . . 62

Exhibit 5-4. Guidance on Working With Patients Who Are Dependent on Opioids

and Not Currently in Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Exhibit 5-5. Guidance on Working With Displaced Patients Treated by

Pain Clinics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Exhibit 6-1. Pregnant Women at Special Risk From Influenza . . . . . . . . . . . . . . . . . . . . 66

Exhibit 6-2. Racial and Ethnic Minorities Disproportionately Affected by

Influenza. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Exhibit 6-3. Potential Effects of Influenza Pandemic on Behavioral Health

Treatment Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

Exhibit 6-4. Pandemic Education Provided to Staff and Residential Patients . . . . . . . . 69

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 Exhibits

Exhibit 6-5. Examples of Pandemic Influenza Planning Assumptions. . . . . . . . . . . . . . . 71

Exhibit 7-1. Tabletop Exercise for Opioid Treatment Programs. . . . . . . . . . . . . . . . . . . . 75

Exhibit 7-2. Beneficial Networking at a Tabletop Exercise. . . . . . . . . . . . . . . . . . . . . . . . 76

Exhibit 7-3. Effect of Timing Decisions on Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

Exhibit 7-4. Examples of Recovery Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

ix
Foreword

This Technical Assistance Publication (TAP), Disaster Planning Handbook for Behavioral
Health Treatment Programs, provides guidance, and the underlying rationale, for management
and staff as they work together to create a comprehensive, scalable, and flexible disaster plan.
This resource can be used by management and the program’s disaster planning team as they
develop or update program processes, procedures, and written reference tools that support a
rapid and effective response when a disaster occurs.

The TAP is intended to support the behavioral health treatment program at any stage of the
disaster planning process. A program in the beginning stages can use the TAP as a step-by­
step guide, whereas the program with a well-developed plan can consult the TAP for ideas on
how to make improvements. In either case, disaster planning should be considered an evolving
process, and the plan itself should be viewed as a living document that must regularly be
reviewed, exercised, and updated.

Guidance in this TAP aligns with Federal guidelines and current best practices in disaster
planning, including recommendations for protecting people’s health, which includes their
behavioral health, in the case of an emergency (U.S. Department of Health and Human
Services [HHS], 2009b, 2011a); for integrating behavioral health into the Nation’s overall
disaster preparedness, response, and recovery efforts (U.S. Department of Homeland
Security [DHS], 2011a); for planning across all threats and hazards (DHS, 2011b); and for the
participation of businesses and nonprofit organizations in the Nation’s preparedness (White
House, 2011). A panel of field reviewers, including behavioral health services providers with
experience in disaster preparedness and response, contributed and reviewed the content to
ensure that this document realistically reflects how behavioral health services programs can
respond to the challenge of disaster preparedness and response.

This TAP advances the Substance Abuse and Mental Health Services Administration’s
Strategic Initiatives, which provide a framework for addressing mental and substance use
disorders, building supportive communities, and improving the health of all Americans. An
overarching aim within these initiatives, “Achieving Excellence in Operations,” is advanced
when behavioral health treatment programs adopt best practices for disaster planning. A
second aim, “Improving the Nation’s Behavioral Health Care,” is advanced when Americans
are provided with essential behavioral health services during and following disaster.

Pamela S . Hyde, J .D .
Administrator
Substance Abuse and Mental Health Services Administration

H . Westley Clark, M .D ., J .D ., Frances M . Harding Paolo del Vecchio, M .S .W .

M .P .H ., CAS, FASAM Director Director
Director Center for Substance Abuse Center for Mental Health
Center for Substance Abuse Prevention Services
Treatment Substance Abuse and Substance Abuse and
Substance Abuse and Mental Health Services Mental Health Services
Mental Health Services Administration Administration
Administration

xi
Introduction

This Technical Assistance Publication (TAP), Disaster Planning Handbook for Behavioral
Health Treatment Programs, provides guidance for developing or improving the behavioral
health treatment program’s disaster plan. This document provides guidance for program
staff members on reducing their facility’s exposure to threats and hazards and retaining and
restoring the program’s capacity to function when a disaster does occur. A disaster plan is an
essential reference for program staff in a disaster situation—the planning process is the path
through which preparedness becomes possible.

A disaster plan describes procedures for ensuring safety in a disaster, reducing the potential
for damage from a disaster, and maintaining or rapidly resuming essential services during
and after a disaster. The plan details procedures for the quick and efficient linking of clients
to other appropriate sources of care when the program itself cannot provide that care. It also
describes processes for the reengagement of clients once the program can again offer regular
services.

The TAP addresses planning issues for staff at programs that provide treatment for mental
or substance use disorders, or both. This guidance addresses the planning needs specific to
programs that offer prevention services, outpatient or residential treatment, medically managed
detoxification, and medication-assisted treatment. The TAP also covers planning issues specific
to at-risk populations (e.g., children, senior citizens, pregnant women, those with chronic
medical disorders, those with pharmacological dependency). This guidance is to be considered
supplemental to, and is not in conflict with, requirements by healthcare licensing or accreditation
bodies (e.g., State licensing departments, CARF International, The Joint Commission) specific
to disaster planning for programs affiliated with them. All programs are required to be in
compliance with any regulatory requirements established by applicable Federal and State
regulations or laws. It is beyond the scope of this TAP to cover specific regulatory requirements.
Providers should obtain guidance directly from applicable regulatory entities.

Audience for This TAP

This TAP is intended for use by the disaster planning team of the behavioral health treatment
program and others responsible for management and oversight of preparedness. This team may
include program administrators responsible for developing and activating the organization’s
disaster plan, as well as senior staff members and clinicians who play leadership roles in
developing and testing the plan, coordinating staff training of the plan, and activating the plan
in an actual incident. The TAP also may be useful to executive directors and other members of
management in helping them understand their specific roles in the disaster planning process and
why their involvement and support are so important. State disaster behavioral health treatment
coordinators may find the TAP helpful in supporting their efforts to promote standardized
disaster planning, response, and recovery of mental health services and substance abuse
treatment programs in coordination with State, Federal, and jurisdictional plans.

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Disaster Planning Handbook for Behavioral Health Treatment Programs

Organization of This TAP

Chapter 1 provides the rationale for the planning process. It also describes the development
of a written disaster plan. Creation of the written document helps focus the disaster planning
process, while the plan itself becomes a reference tool for use in any emerging disaster
situation. Once completed, the plan must be regularly updated to ensure that it remains
current and relevant.

Chapters 2, 3, and 4 provide guidance for creating a disaster planning team and describe steps
to develop content for each part of the disaster plan. Chapter 5 provides guidance specifically
for management of prescription medications. Chapter 6 addresses the content that would
be included in a Pandemic Appendix to the disaster plan. Chapter 7 provides information
on completing the basic plan; testing, activating, deactivating, and updating the plan; and
coordinating with the community as it recovers from the disaster.

Worksheets (located in Appendix B) are tied to the chapter guidance. The disaster planning team
can refer to these worksheets to identify steps and document actions and arrangements. Some
worksheets are checklists to guide the planning process whereas others, when completed, can
become part of the written plan. Appendix D includes useful disaster planning Web resources.

Behavioral Health Terms

A few key terms from the behavioral health field are defined here, for clarity.

behavioral health—Behavioral health is used in this TAP to refer to a

state of mental/emotional being and/or choices and actions that affect wellness. Behavioral health problems
include substance abuse or misuse, alcohol and drug addiction, serious psychological distress, suicide, and
mental and substance use disorders. This includes a range of problems from unhealthy stress to diagnosable
and treatable diseases like serious mental illnesses and substance use disorders, which are often chronic
in nature but that people can and do recover from. The term is also used to describe the service systems
encompassing the promotion of emotional health, the prevention of mental and substance use disorders,
substance use, and related problems, treatments and services for mental and substance use disorders, and
recovery support. (Substance Abuse and Mental Health Services Administration, 2011a, p. 1, footnote i)

client and patient—Client is used inclusively to refer to any recipient of behavioral health
treatment services. Patient is used only when the reference is specifically to an individual in
a medically directed residential treatment program, undergoing medical detoxification, or
receiving medication-assisted treatment (e.g., methadone maintenance treatment).

co-occurring—The term refers to co-occurring mental disorder and substance use disorder. A
client with co-occurring disorders may have one or more of both types of disorders.

program—Program is frequently used in this TAP in place of the full phrase behavioral health
treatment program, meaning a program providing services for the treatment or prevention
of mental or substance use disorders, or both. To avoid lengthy phrasing, the word program
is also used to represent the people who work in the program and who develop and execute
disaster planning activities (e.g., “The program has an obligation to prepare for potential
disasters because . . . .”). The TAP provides guidance as if a program creates only one disaster
plan. However, the program with multiple facilities (i.e., buildings or sites) will need to tailor
its plan for each location.

xiv
 Introduction

Disaster Terms
Below are several disaster terms related to this TAP. Unless otherwise indicated, the
definitions provided are verbatim from the cited source materials.

disaster—An occurrence of a natural catastrophe, technological accident, or human-caused

event that has resulted in severe property damage, deaths, and/or multiple injuries. (Federal
Emergency Management Agency [FEMA], 2010a, p. B-3)

emergency—Any incident, whether natural or human-caused, that requires responsive

action to protect life or property. Under the Robert T. Stafford Disaster Relief and Emergency
Assistance Act, an emergency means any occasion or instance for which, in the determination
of the President, Federal assistance is needed to supplement State and local efforts and
capabilities to save lives and to protect property and public health and safety, or to lessen or
avert the threat of a catastrophe in any part of the United States. (FEMA, ca. 2011)

Note: The words disaster and emergency are closely related and often used synonymously.
However, in the healthcare field, emergency frequently refers to medical or psychiatric
incidents involving an individual (e.g., a patient having seizures or hallucinations). To avoid
confusion, in this TAP the word disaster is used when referring to any incident that has the
potential to adversely affect a facility’s ability to operate and provide services to clients, even
if the incident is emerging or possibly small in scope. Similarly, in this TAP the term disaster
planning is often used even though FEMA and many jurisdictions use terms such as emergency
planning and emergency operations planning.

emergency management/response personnel—Includes Federal, State, territorial, tribal,

substate, regional, and local governments, nongovernmental organizations (NGOs), private
sector organizations; critical infrastructure owners and operators, and all other organizations
and individuals who assume an emergency management role. Also known as emergency or first
responder. (FEMA, ca. 2011)

hazard—Something that is potentially dangerous or harmful, often the root cause of an

unwanted outcome. (FEMA, ca. 2011)

hazard identification and risk assessment (HIRA)—A process to identify hazards and
associated risk to persons, property, and structures and to improve protection from natural
and human-caused hazards. HIRA serves as a foundation for planning, resource management,
capability development, public education, and training and exercises. (FEMA, 2008) Another
term for this assessment is threat and hazard identification and risk assessment (THIRA).

incident—An occurrence, natural or human-caused, that requires a response to protect life or

property. Incidents can, for example, include major disasters, emergencies, terrorist attacks,
terrorist threats, civil unrest, wildland and urban fires, floods, hazardous materials spills,
nuclear accidents, aircraft accidents, earthquakes, hurricanes, tornadoes, tropical storms,
tsunamis, war-related disasters, public health and medical emergencies, and other occurrences
requiring an emergency response. (FEMA, ca. 2011)

mitigation—Those capabilities necessary to reduce loss of life and property by lessening the
impact of disasters. Mitigation capabilities include, but are not limited to, community-wide risk
reduction projects; efforts to improve the resilience of critical infrastructure and key resource
lifelines; risk reduction for specific vulnerabilities from natural hazards or acts of terrorism;
and initiatives to reduce future risks after a disaster has occurred. (White House, 2011)

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Disaster Planning Handbook for Behavioral Health Treatment Programs

preparedness—A continuous cycle of planning, organizing, training, equipping, exercising,

evaluating, and taking corrective action in an effort to ensure effective coordination during
incident response. Within the National Incident Management System (NIMS), preparedness
focuses on the following elements: planning, procedures and protocols, training and exercises,
personnel qualification and certification, and equipment certification. Examples: Conducting
drills, preparing homework packages to allow continuity of learning if school closures are
necessary, etc. (FEMA, ca. 2011)

prevention—Actions to avoid an incident or to intervene to stop an incident from occurring.

Prevention involves actions to protect lives and property. Examples include: Cyberbullying
prevention, pandemic influenza sanitation measures, building access control procedures,
security systems and cameras, etc. (FEMA, ca. 2011)

Note: When Institute of Medicine classifications for prevention are applied to behavioral health
(e.g., prevention of mental or substance use disorders), the term prevention can carry the
specific meaning of universal prevention (strategies targeted at the entire population); selective
prevention (strategies targeted at subsets of the total population considered to be at-risk);
and indicated prevention (strategies targeted at individuals who show signs and symptoms
of the disorder) (paraphrased from National Institute on Drug Abuse, 1997). In this TAP, the
intended meaning of prevention (disaster or behavioral health related) can be inferred from the
context.

reconstitution—The resumption of non-emergency operations at a primary facility following

emergency operations at an alternate facility. (FEMA, 2004)

recovery—Those capabilities necessary to assist communities affected by an incident to

recover effectively, including, but not limited to, rebuilding infrastructure systems; providing
adequate interim and long-term housing for survivors; restoring health, social, and community
services; promoting economic development; and restoring natural and cultural resources.
(White House, 2011)

Note: In the behavioral health treatment field, recovery means the remission of symptoms of
mental or substance use disorders, or both. In this TAP, recovery is used as both a behavioral
health term and as a disaster-related term. The meaning in each instance should be clear from
the text.

response—Those capabilities necessary to save lives, protect property and the environment,
and meet basic human needs after an incident has occurred. (White House, 2011)

xvi
Chapter 1—Rationale and Process
for Planning
Disaster planning can save lives, minimize injury and
In This Chapter emotional trauma, protect property and operational
capability, and prevent or reduce interruptions in
• Essential Partners in treatment. For all of these reasons, the behavioral
National Preparedness health treatment program should coordinate with
• Providers of Essential its community long before disaster strikes, to
Services plan and prepare for a rapid, effective response to
disaster. Program staff also need to document those
• Partners in Community preparations in a format that is readily understood
Preparedness and easy to navigate so that personnel can refer to
the plan under time-sensitive conditions. This chapter
• Mandates for Disaster
covers the reasons for disaster planning, explains
Planning
the basis for the kind of planning proposed in this
• All-Hazards Planning Technical Assistance Publication (TAP), and provides
an overview of the written disaster plan.
• The Planning Process
• Continuity Planning
• Overview of the Written Essential Partners in National
Disaster Plan Preparedness
• Drafting a Usable Plan Our Nation faces a wide range of threats and hazards,
including acts of terrorism, cyber attacks, pandemics,
Worksheet (see Appendix B) and catastrophic natural disasters. Communities can
address the risks these threats and hazards pose by
• B1 Checklist for the Written working together using a systematic approach that builds
Disaster Plan on proven preparedness activities. (U.S. Department of
Homeland Security [DHS], 2011b, p. 1)

National preparedness is the shared responsibility of our

whole community. Every member contributes, including
individuals, communities, the private and nonprofit sectors,
faith-based organizations, and Federal, state, and local
governments. (DHS, 2011c, p. 1)

As suggested by these quotations from national

preparedness documents, disaster readiness
is not accomplished ad hoc or in isolation. It is
done systematically and in coordination with all
stakeholders. To the extent that behavioral health
treatment programs exist in the community and serve
the community, they are essential partners in national
preparedness.

1
Disaster Planning Handbook for Behavioral Health Treatment Programs

Providers of Essential Services safe place to go to complete their initial

recovery goals.
The behavioral health treatment program has
a special obligation to prepare for disasters • Patients on psychotropic medications (e.g.,
because it provides essential services. Disaster antipsychotic medications, anti-anxiety
services in support of behavioral health are medications) who obtain their medications
named in Emergency Support Function (ESF) at the program, or who are assisted by staff
#8 (Public Health and Medical Services) of the in taking their medications regularly, are
National Response Framework (DHS, 2013) at risk of serious withdrawal symptoms
and in a Recovery Support Function (Health (e.g., seizures, delirium tremens) if the
and Social Services) of the National Disaster medications are stopped abruptly. Similarly,
Recovery Framework (DHS, 2011a).* patients receiving methadone treatment for
opioid dependence may develop withdrawal
By their nature, disasters have an impact on symptoms (e.g., tremors, hallucinations) if
behavioral health: their treatments are interrupted.
• At-risk populations (e.g., children, senior
Most people who experience a disaster, whether
citizens, pregnant women, those with
as a victim or responder, will have some type
chronic medical disorders, those with
of psychological, physical, cognitive, and/or
pharmacological dependencies) may face
emotional response to the event. Most reactions
unique hardships and challenges if suddenly
are normal responses to severely abnormal
deprived of their program’s support.
circumstances. (American Medical Association,
2005, p. 2) Just as important, disaster planning can
prepare the program for providing behavioral
Thus, there can be significant demand for health services to new clients:
behavioral health services as a result of a
disaster and significant consequences if a • In the weeks and months following a
program suddenly closes or is forced to reduce disaster, the program may experience
services. a surge in demand for services from
individuals for whom the disaster has
Disaster planning can prepare the program created a need for assessment or treatment
for continuing to provide behavioral health services and from clients previously
services to its existing clientele. Otherwise: treated at other programs who have been
displaced from their local community.
• Clients in recovery may relapse to
substance abuse, or their psychiatric • A program that has been spared by the
symptoms may recur, at the very time they disaster may be called on to provide aid to
must cope with the uncertainties, traumas, other programs (e.g., treating guest clients,
and losses caused by the disaster. sharing medications, lending staff members)
or to other community organizations (e.g.,
• Patients receiving medically managed sharing resources, reassigning staff).
detoxification for alcohol and drug
abuse are at risk of serious medical and • Staff members may be asked, based on
psychological complications if the process their training, to provide emergency
is interrupted. community-based behavioral health
services (e.g., crisis counseling or
• Patients in residential treatment programs intervention, psychological first aid,
that have closed may have no other assessments and referrals).
*
The Federal agencies that coordinate these Federal preparedness plans are the Office of the Assistant Secretary
for Preparedness and Response, U.S. Department of Health and Human Services (ESF #8), and National
Disaster Recovery Planning Division, Federal Emergency Management Agency, DHS (National Disaster Recovery
Framework). The behavioral health treatment program typically does not work directly with these Federal agencies
but rather through local disaster planning leadership. See Coordinate Planning With Others, in Chapter 2.

2
 Chapter 1―Rationale and Process for Planning

Partners in Community use disorder and know how to route people

Preparedness displaying such signs to appropriate services.
This would better ensure that responder
The behavioral health treatment program’s interactions with affected individuals are
disaster planning contributes to the overall managed appropriately, that the identified
preparedness of the community. Proper individuals receive the behavioral health
planning helps prepare for potential rapid services and protections they require, and that
surges of vulnerable populations needing their due process rights are protected.
behavioral health services and for the rapid
transition of services to other locations when
the program and community are overwhelmed. Mandates for Disaster Planning
Such planning is critical; it has been Disaster planning is not just prudent and
estimated that, after a disaster, a community’s practical, it is required:
healthcare facilities may experience a surge
for behavioral health services that could range • Most States require a disaster plan for
from 4 to 50 times higher than the surge for program licensure.
medical care (Meredith, Zazzali, Shields, • The Joint Commission and CARF
Eisenman, & Alsabagh, 2010). A variety of International each require a disaster plan
factors or “triggers” are theorized to contribute for accreditation.
to elevated demand for behavioral health
services in a disaster situation. These include • To receive Medicaid reimbursement,
restricted movement (e.g., quarantine, shelter programs offering mental or substance
stays, evacuation); limited resources (including use disorder treatment services must be in
denial of, limitation of, or suspended full compliance with licensure regulations,
access to care); exposure to trauma (both including those pertaining to disaster
direct and indirect, such as through media planning.
exposure); limited information (including
• Disaster planning is a requirement for
insufficient or inaccurate information or
opioid treatment program certification.
rumors); and perceived personal or family
risk. Representatives of behavioral health • Behavioral health treatment programs
treatment programs can work with community that are part of healthcare coalitions
planners to put into place the structures receiving funds through the Hospital
and processes that support people’s adaptive Preparedness Program are obligated to
and appropriate responses to these triggers plan for response to common medical
(Meredith, Eisenman et al., 2011). disasters (Office of the Assistant Secretary
for Preparedness and Response, 2012).
Another significant contribution the treatment
program can make as it participates in its • Federally qualified health center
community’s disaster readiness is to advocate programs, rural health clinics, and other
for the needs of people with behavioral health primary care safety net providers are
disorders, including people with chronic obliged, as extensions of the Federal
mental disorders, people with new-onset Government, to conduct disaster planning.
disorders triggered by the disaster, and Ideally, the disaster planning process helps
people who are physiologically dependent the program identify and obtain the resources
on medications or illicit drugs (Rabins, and training it needs to forge an effective
Kass, Rutkow, Vernick, & Hodge Jr., 2011). response to a range of potential calamities.
Programs also can advocate for training As staff members work together across
of emergency responders so that they can departments to create and test the plan, they
recognize signs of severe psychological build relationships that will be important
trauma, cognitive incapacity, or a substance when they must work together under the

3
Disaster Planning Handbook for Behavioral Health Treatment Programs

intense conditions of a real disaster. The The National Preparedness System

planning process also provides program presents a collaborative, whole-community
staff with opportunities to meet and build approach for building a secure and resilient
relationships with other professionals from Nation that can confront any threat or
the community who will be key partners in hazard. Components include: identifying
the event of a disaster. As a result, the entire and assessing risk, estimating the level of
infrastructure of the program is strengthened capabilities needed to address those risks,
and more adequately prepared for response to building or sustaining the required levels
unusual incidents of any kind and scope. of capability, developing and implementing
plans to deliver those capabilities, validating
and monitoring progress, and reviewing
All-Hazards Planning and updating efforts to promote continuous
improvement (DHS, 2011b).
This TAP describes an all-hazards approach
to planning. All-hazards planning means that NDRF is a statement of the principles
planners prepare for response to a full range guiding effective recovery from large-scale
of threats and dangers but with a focus on or catastrophic disasters. Its objective is to
the specific incidents most likely to occur in guide a unified and collaborative response
their area (Federal Emergency Management for restoring, redeveloping, and revitalizing
Agency [FEMA], 2010a). This kind of planning communities (DHS, 2011a).
begins with an extensive risk assessment
based on probabilities of anticipated events NIMS identifies the terms, protocols,
occurring in the program’s or facility’s specific procedures, and standards that should
locality. Based on the risks identified, a be used so that disaster response can be
program addresses the capabilities needed to effectively coordinated at the local, regional,
respond. For example, the risk assessment State, and Federal levels. NIMS provides all
may document that the program is situated partners involved in a disaster response a
in an area susceptible to flooding. The common language and a standardized way
program begins with response plans for to communicate about their responsibilities,
flooding (e.g., taking preventive actions to activities, and functions. A NIMS-modeled
protect the facility from flooding, developing disaster plan is flexible: it can be scaled up
an evacuation plan, creating plans for clients or down, depending on the size, scope, and
and patients to be treated outside the flood complexity of the disaster, and it can be
area, ensuring that records are backed up in readily integrated into the plans of other
another location). These plans can be adapted responding organizations (DHS, 2008).
when responding to other types of disasters.
A basic premise underlying NIMS is that
incidents typically are managed at the local
The Planning Process level first. In the vast majority of incidents,
local resources provide the first line of
The planning process described in this TAP emergency management and incident response.
aligns with that recommended for entities If additional or specialized resources or
such as State, territorial, Tribal, and local capabilities are needed, State governors may
governments; planners in other disciplines, request Federal assistance. However, local
organizations, and the private sector (FEMA, jurisdictions retain command, control, and
2010a); and courts (National Center for authority over response activities in their areas.
State Courts, 2007). This process is based
on Federal policies for disaster planning, Behavioral health treatment programs—
including the National Preparedness System, whether public, private, or nonprofit—should
the National Disaster Recovery Framework develop disaster plans that comply with
(NDRF), and the National Incident NIMS (FEMA, 2006). A NIMS-compliant
Management System (NIMS).
4
 Chapter 1―Rationale and Process for Planning

program agrees to manage disaster incidents Continuity Planning

using the Incident Command System
(see Chapter 3) and to coordinate with Behavioral health programs need to plan not
other responders for decisionmaking and only for responding to a disaster as it hits
public communication. The program also (disaster planning), but also for continuing
agrees to train key staff members in NIMS essential operations under a broad range of
preparedness, participate in internal and circumstances that could follow a disaster
external training exercises, and incorporate (continuity planning). Thus, a vital part of
NIMS concepts into its disaster plan. the program’s overall disaster plan is its
business continuity plan, commonly called its
The behavioral health treatment program continuity of operations plan, or COOP plan.
should use the NIMS approach to disaster The latter term originally referred to planning
planning and training for the following by government entities, but it has been
reasons: adopted by businesses and organizations.

• NIMS was developed based on best Continuity planning requires a program’s

practices and has been extensively tested personnel to consider the threats that
throughout the country, proving its could adversely affect essential functions;
effectiveness in providing a framework for determine the personnel, vital information
a coordinated disaster response. (e.g., patient medical records including
prescription records), and other resources
• Almost all government and community required to continue those essential functions;
training on disaster response is based on develop plans for providing essential
NIMS. functions onsite or at alternate locations if
• Staff members who understand NIMS and needed; make advance arrangements for
prepare to respond using NIMS protocols obtaining the resources necessary to support
will more readily fit into their community’s essential functions throughout the disaster
response activities. The program, and recovery phases; and plan for the safety
therefore, will be in a better position to get of all personnel during these periods. The
and to give help in a disaster. continuity plan can be scaled up or down as
needed to accommodate the quantity and
• Adhering to NIMS enables the program to variety of clients who need services. Elements
better use incoming resources, including of the continuity plan may be activated either
deployed staff and volunteers. in conjunction with a disaster declaration by
• Program staff members who may be called a government official or independent of such
on to serve as part of an external disaster a level of response.
response (e.g., as members of the State’s
Examples of scenarios in which a program
behavioral health disaster response team)
would implement a continuity plan include
must be credentialed in and operate within
the following:
the NIMS structure.
• When the program must cease provision
of nonessential services due to a sudden
Appendix D, Disaster Planning Web Resources,
reduction in resources, infrastructure,
provides links to various Federal planning
guidelines.
or available personnel (e.g., during a
pandemic)
• When the program cannot provide
essential services to clients at its original
location (e.g., when the facility is damaged
due to a fire or access is blocked due to a
chemical spill or a blizzard)

5
Disaster Planning Handbook for Behavioral Health Treatment Programs

• When evacuation to another geographic These individuals may benefit from an

area is recommended or mandated (e.g., established or temporary telephone hotline
because of an advancing hurricane) answered by trained crisis intervention
and referral staff (possibly nonclinicians or
• When staff and resources are diverted
prevention staff).
to provide urgent care to community
members in distress • Patients who have been stabilized for long
periods on antidepressants, antipsychotics,
Continuity planning helps the program
or medications for opioid addiction who
prepare for meeting the needs of existing
are not able to obtain prescription refills
clientele and for a possible increase in
and are in danger of sudden medication
demand that can occur after a disaster, either
withdrawal or relapse to psychiatric or
in the immediate aftermath or in the months
addiction symptoms. These patients may
that follow. Increases may occur both in
need evaluation and referral to resources.
the number of individuals needing services
and in the severity of clients’ addictions • Patients on opioid medication for pain
and psychiatric conditions. Characteristics who cannot obtain services from their
(e.g., age, gender, culture, English-language physician, are facing or experiencing
proficiency, home location, behavioral health withdrawal, and request help from the
and medical conditions) of guest clients or treatment program. These patients may
new clients after a disaster may differ from need referral to pain specialists.
those of the program’s preexisting clientele.
The program may have to adapt quickly to
accommodate a variety of clients and their Overview of the Written
needs, such as:
Disaster Plan
• Current clients who are facing extra The written disaster plan needs to be flexible
stressors arising from the disaster in its application and comprehensive, but
and need extra counseling, psychiatric not overwhelming, in scope. Ideally, it is
monitoring, or other support to maintain organized so that it can be quickly referenced
and continue recovery from a behavioral in a disaster situation.
health disorder.
The components of a disaster plan are briefly
• Guest clients from other treatment
described in the following section. More detail
programs or under physician care who
is provided in Chapters 2, 3, and 4, which
have been displaced by the disaster and
outline the processes by which the disaster
who come to the program for short- or long­
planning team gathers information, makes
term assistance.
planning decisions, and compiles information
• Individuals who completed treatment or into a written disaster plan. Worksheet
discontinued services prior to a disaster B1 (Appendix B) can be used as a checklist
but whose recoveries are now threatened for assembling plan components into one
as a result of the event. document.
• Individuals with an ongoing, untreated
mental or substance use disorder (or both) The Basic Plan
who need treatment to prevent further
The introductory section of the basic
deterioration or to prevent an escalation
plan includes a statement of purpose and
of dangerous medical or psychological
objectives and other summary information,
symptoms.
including the scope of the plan, the
• Family members of clients who need populations served by the program, and the
assistance for their loved ones, or for program’s essential functions. Also included
themselves, to alleviate concerns. in the basic plan are a situation overview

6
 Chapter 1―Rationale and Process for Planning

(e.g., the hazards the program is most likely A functional annex should not repeat
to face, the program’s response capabilities, information in the basic plan. It should
the steps that have been taken to reduce risk) add only those details that are necessary to
and a section on planning assumptions. perform the procedure.

Following the introductory section, the basic

plan contains a statement about the concept Hazard-Specific Appendices
of operations (i.e., the organization’s overall In its initial work, the disaster planning team
approach in responding to disaster). This conducts or gathers, from partner agencies in
statement should address procedures for the community, a hazard identification and
activating and deactivating the plan and the risk assessment (HIRA; see Chapter 2). The
general sequence of actions to be taken—by HIRA identifies the specific types of threats
whom—before, during, and after an incident. or risks most likely to occur and the potential
The statement should also provide the impact of each type on the program. In
following: a list of the personnel positions response to each identified hazard, threat, or
authorized to make requests for outside aid incident, the disaster planning team develops
or assistance, the conditions under which response procedures based on industry
to request aid, the procedures for managing safety standards and regulations (e.g.,
requests to give aid, and a list of the those issued by the Occupational Safety and
resources that can be used in those efforts. Health Administration). These procedures
Methods and schedules for updating the plan, are attached as a hazard-specific appendix
communicating changes to staff, and training to the basic plan. For example, if the
staff on the plan should also be included in HIRA identifies hurricanes and hazardous
the concept of operations. materials spills as possible hazards to the
program, the planning team would develop
Functional Annexes two appendices, one for each hazard.

A set of instructions for a specific hazard A hazard-specific appendix should not repeat
response procedure is referred to as a information that is in either the basic plan
functional annex. Each annex is separately or any functional annex, both of which
attached to the disaster plan to avoid provide instruction applicable to all hazards.
cluttering the basic plan with too much It should add only those details that are
detail. This structure also makes it easier to specific to the hazard being addressed. If the
update and revise individual components of details are few, hazard-specific information
the disaster plan as needed. can be presented in a few sentences at the
end of each functional annex. For example, a
A functional annex can be as short as a functional annex of instructions for backing
paragraph or as long as several pages. up and saving computer data may include
Examples of functional annex topics include separate procedures for tornado scenarios,
procedures for the emergency phase, such in which there is little time to act, and for
as facility evacuation, sheltering-in-place, hurricane scenarios, for which more warning
and handling the media. The continuity time is available.
plan is a functional annex that is often
the largest section of the overall disaster Alternatively, an appendix can be added that
plan (development of this functional annex contains all special instructions relative to a
is addressed in Chapter 4). Decisions on particular type of hazard, threat, or incident.
whether to include procedural instructions Each specific appendix is inserted after
in the basic plan or in a separate functional the basic plan and the functional annexes.
annex depend on the size and complexity of (See Chapter 6 for guidance on preparing a
the program and the level of sophistication Pandemic Appendix.) The disaster planning
in planning that the program has attained. team chooses the format for its hazard­

7
Disaster Planning Handbook for Behavioral Health Treatment Programs

specific information that makes the most can be taken quickly. The plan is a guide,
sense for the personnel who will be using the not a script. It is a useful tool for training
disaster plan when an incident occurs. staff, evaluating exercises and drills, and
sharing with other community partners who
participate in disaster response. In a real
Implementing Instructions disaster, the people who execute the plan will
Material that helps staff members perform have to adjust their actions as the situation
essential tasks during a disaster—referred to dictates and as facts replace planning
as implementing instructions—are attached assumptions.
to the back of the basic plan, with copies
distributed to pertinent personnel. Typically, Drafters of the plan are encouraged to
the material includes the program’s safety- aim for a simple and flexible plan and to
related policies and procedures; these should avoid creating a document that attempts
be periodically reviewed and updated with to cover all possible contingencies; that
a schedule in place to communicate to staff goal is impossible, and the result will be an
about changes and provide recurrent training. unwieldy, difficult-to-navigate document. The
plan should be written in easy-to-understand
Implementing instructions also can include language that makes use of agreed-on and
job-related aids that staff can use to perform defined terms and that provides concrete,
disaster response tasks (e.g., checklists, actionable guidance (FEMA, 2010a).
worksheets, laminated wallet cards or sheets,
scripts that staff can use when providing The plan can be maintained in electronic
disaster-related information to consumers form, so long as it is accessible to all key
and the public). personnel. Paper backup copies should also be
kept in case of a situation in which electrical
Other materials that can be attached to the power or computer systems are down. Paper
plan include Memoranda of Agreement (see versions of the plan must be dated and old
Chapter 3 and Appendix F), building floor versions replaced and destroyed to eliminate
plans, community maps, and one or more of confusion. Electronic version control is also
the completed worksheets from Appendix B important; it can be helpful to track changes
such as Worksheet B7, Incident Command on a separate grid sheet attached to the
System Positions. The types of implementing document, to replace the date as changes
instructions that can be attached to the basic are made, and to archive old versions so
plan are discussed in subsequent chapters that personnel access only the most current
and are included in the checklist found in version. Communication to staff of any
Worksheet B1, in Appendix B. updates should be part of the program’s
standard safety practice.

Drafting a Usable Plan

A key objective is to organize the material
so that information can be referenced
immediately when needed and actions

8
Chapter 2—Beginning the Disaster

Planning Process

This chapter provides guidance on forming a disaster

In This Chapter planning team, obtaining clarity on the scope and
responsibilities for the team, and gathering initial
• Select a Disaster Planning data. A key step in this process is integrating with
Team Leader and Team the other entities in the community whose efforts,
• Obtain Support From the when disaster occurs, will be orchestrated through
Organization’s Leadership an Incident Command System (Chapter 3 addresses
the Incident Command System). Planning activities
• Review Requirements for recommended in this chapter are listed in checklist
Disaster Planning form in Worksheet B2 (in Appendix B).
• Coordinate Planning With
Others
Select a Disaster Planning Team Leader and
• Educate the Community
Team
About Behavioral Health
Services Disaster planning is a cycle that begins with planning
and moves through various stages of training,
• Prepare a Hazard
testing, evaluating, revising, and further planning
Identification and Risk
as circumstances evolve. This cyclical process helps a
Assessment
program create a suitable plan for its facility that can
• Specify Planning Objectives be effectively implemented by staff and kept current.
and Assumptions Because of the continuous nature of this process,
the program’s disaster planning team needs to be
Worksheets (see Appendix B) a permanent part of the organization. Its ongoing
responsibilities can include making revisions to the
• B2 Checklist for Disaster plan (based on insights gained through testing or
Planning actual disaster response, or because the program has
• B3 Checklist of State and changed), monitoring the plan as a whole to ensure
Community Representatives that it remains coherent, and coordinating testing and
and Groups training based on the plan.

• B4 Checklist of Disaster The program with a small staff may include every
Planning Discussion Topics employee on its disaster planning team, whereas a
large program can assemble a team representing
various departments or functions of the organization.
The program with several locations will generate one
disaster plan, but each separate facility (or its function)
needs to be represented on the disaster planning team
to ensure that its particular needs, vulnerabilities,
and client population are reflected in the plan. Site-
specific safety personnel or leadership would be logical
members of the disaster planning team.

As another option, a program’s existing standing

committee (e.g., safety committee) can double as

9
Disaster Planning Handbook for Behavioral Health Treatment Programs

the disaster planning team. Typically, and their roles in its implementation (Exhibit
this committee includes individuals or 2-1). The team leader also typically serves as
departments responsible for safety (e.g., fire the organization’s representative at disaster
drill coordination, building and parking lot planning meetings in the community and is
safety, computer systems security). the liaison for the program as it engages in
local or regional disaster planning exercises.
Members of the planning team are described
in the following sections. The person who leads the disaster planning
team is not necessarily the person who will
be assigned to lead the organization during
Team Leader its response to a disaster. The latter role is
The leader of the disaster planning team may called Incident Commander, and the position
hold any of several titles (e.g., emergency and its duties are described in Chapter 3.
manager, emergency coordinator, business
continuity manager, continuity of operations
Representatives From Across Departments
coordinator). If the program is small, the
program’s executive director or facility All departments of the facility or
administrator may serve in this position. organization, especially those providing
Alternatively, the executive director may essential functions, should be represented on
delegate responsibility for managing the the disaster planning team. Members should
plan to someone else who has leadership include both clinical and nonclinical staff,
and organizational skills, is familiar with especially those involved in residential or
all aspects of the organization, and has round-the-clock services, and administrative
experience with disaster planning or has a staff and management. Everyone has a role
willingness to learn. in disaster preparedness and response.

Typically, the leader convenes and conducts Staff members who do not serve on the
team meetings, ensures that team members planning team will become involved in later
receive the training they need to contribute stages of planning, when sections of the draft
effectively to disaster planning, and works plan are circulated for comment and when
with team members to gather information. the plan is tested in exercises and drills.
The leader is responsible for ensuring that Feedback from these staff members can be
the plan is developed, tested, and maintained used to improve the plan. This testing process
and that the organization’s leadership and is described in Chapter 7.
departments are informed of the disaster plan

Exhibit 2-1. Importance of Comprehensive Training for All Staff

During a recent response to a highly unexpected earthquake at our program in Virginia, a “debrief”
was scheduled with representatives from both administrative and clinical staff to discuss response to
the event. During that debrief, what became clear was that the administrative staff had not been fully
informed on the particulars of who would take charge of various disaster-related responsibilities or
specific disaster roles. Prior to this event, the assumption was that only key staff needed full training on
all aspects of the disaster plan. This proved to be a false assumption. Although role-specific training is
important, there is a danger that it may become too targeted and not allow for a big-picture view of all
parts and participant roles in a response. The debrief resulted in changes to training requirements and
a new appreciation for providing all staff with more comprehensive training so that the disaster-related
roles of everyone in the organization are clear.

Source: Elizabeth Ludeman-Hopkins, personal communication, January 22, 2012.

10
 Chapter 2—Beginning the Disaster Planning Process

It is important to involve all staff members organization’s leader serves in direct authority
either on the disaster planning team or in over the team and maintains a direct line
support of the work of the team because: of communication with the team leader to
get regular updates related to planning and
• Broad staff involvement ensures that all response activities. The leader lends credibility
critical operations are addressed in the plan. to the disaster planning by participating on
the team as other duties permit.
• Ongoing input from all staff members can
keep the disaster planning team aware of
Other ways that the program’s leader
changes in equipment or procedures that
promotes the importance of this project
may affect disaster operations.
include appointing the members of the team
• Staff members are more likely to follow a (rather than delegating this task), ensuring
plan they have helped develop. that all relevant departments are included
on the team, and allocating resources from
• Staff members already familiar with the organization to the team (e.g., space to
their roles are less likely to need last- meet; compensated time for team members
minute training when the plan must be to obtain training, attend meetings, and
implemented. work on assigned team tasks). Leadership
• Staff members familiar with the disaster (e.g., managers and supervisors) can consider
response plan may be less likely to specifying disaster planning responsibilities
experience panic, fear, and anxiety when in the job descriptions for team members and
an incident occurs. taking into account those duties during each
employee’s annual review.
• Staff members who are engaged in
developing the plan may be more likely
to recognize the importance of creating Members of the disaster planning team
emergency plans for their homes. During can gain knowledge in all aspects of
a disaster, having home plans can reduce disaster planning and response through the
staff members’ anxiety over their families’ Independent Study Program of the Emergency
Management Institute (EMI), Federal
safety and enable those staff members
Emergency Management Agency (FEMA).
to be physically and mentally present for
No-cost, online courses offered by EMI take
their job functions. approximately 3 hours to complete. They can
be accessed at http://training.fema.gov/IS.

Obtain Support From the

Organization’s Leadership
Review Requirements for Disaster
As with any kind of planning, disaster planning
has costs associated with it. Management Planning
shows its support by considering the budget The disaster planning team should review
impact of the planning process, as well as pertinent accreditation, licensing, or
disaster preparation, response, and recovery reimbursement requirements, as well as
activities. To fully prepare the organization any State and Federal regulations or laws
for continuity of operations, management may governing disaster planning. The team
need to develop a multiyear budget plan. should identify its program’s planning
requirements as dictated by its State, The
An organization’s leader contributes to the Joint Commission, CARF International,
success of disaster planning by providing Medicaid, and any other bodies that govern
the planning team with specific expectations its operations. Team members also should
regarding the scope of its mission and become familiar with Federal guidelines
encouraging everyone in the organization to regarding disaster planning.
cooperate with the team’s work. Typically, the
11
Disaster Planning Handbook for Behavioral Health Treatment Programs

Mandates may require the program to planning of other behavioral health treatment
conduct general disaster planning, as well as programs, the State, the local jurisdiction,
specific planning for pandemic influenza (see neighboring businesses and voluntary
Chapter 6). Programs receiving State funding organizations, and Federal coordinating
may be required to have staff members (who agencies. Advance coordination can make the
are credentialed and ready) participate in program’s efforts in a disaster situation more
a behavioral health disaster response team. productive and the assistance it gives and
When a disaster occurs, such teams may be receives more effective. Treatment programs
mobilized by the State behavioral health are advised to participate in community
departments, or by specific lead organizations coordination of predisaster recovery planning
serving localities, to provide affected members as outlined in the National Disaster Recovery
of the public with psychological first aid, Framework (U.S. Department of Homeland
crisis intervention, assessments and referrals Security [DHS], 2011a).
to ongoing services, public information, and
other services as determined by the State Coordination with neighboring facilities and
authority (Exhibit 2-2). Teams also may be organizations is especially important because
mobilized to support the behavioral health of in any sizable disaster, the first assistance
emergency responders (Exhibit 2-3). is likely to come from or go to neighbors
(DHS, 2008). A behavioral health treatment
program is less likely to receive help in
Coordinate Planning With Others community recovery efforts if neighbors do
not know that the program exists, or if they
The program’s disaster plan should be do not understand that the program provides
developed in coordination with the disaster essential services. The program is also less

Exhibit 2-2. Mobilization of Behavioral Health Responders To Assist Hurricane Evacuees

Colorado opened an empty dorm unit on the campus of the closed Lowry Air Force base for people
who were relocated there after Hurricanes Katrina and Rita. In a gesture of welcome, a bar across the
street from the dorm offered free drinks to the evacuees, with unintended consequences. The dorm
took on the atmosphere of a Wild West town, with heavy drinking, clearly identified gang members,
and prostitutes. Recovery advocates who visited the dorm identified and referred individuals in need of
medication-assisted treatment, mutual-help group meetings, and, in some cases, medical detoxification.
The presence of these recovery advocates helped many evacuees withstand the stress and temptations
of the situation to preserve their recovery and obtain needed services.

Source: Katie Wells, personal communication, May 11, 2010.

Exhibit 2-3. Mobilization of Behavioral Health Responders To Assist

Earthquake Emergency Responders

Steps taken in Haiti included psychological readiness preparation for responders before they were
deployed and assistance with stress management, addiction risks, and other emotional and behavioral
health concerns during deployment. Mental health professionals were embedded in National
Disaster Medical System teams in Haiti and a mental health officer served on the Incident Response
Coordination Team. In addition, responders received systematic post deployment education that
included advice on expected responses and danger signs indicative of emotional and behavioral health
problems and on how to access appropriate follow up resources should they be needed. Overall, this
effort to include mental and behavioral health concerns in the response broke new ground and can
serve as a model for the future.
Excerpted from National Biodefense Science Board (2010, p. 15).

12
 Chapter 2—Beginning the Disaster Planning Process

likely to be included in recovery efforts if Exhibits 2-6 and 2-7 provide examples in
neighbors are unaware of the contributions which behavioral health treatment programs
that the program and its staff can make in networked with other community agencies
responding to disaster. to improve their disaster preparedness.
The various groups with which a program’s
Furthermore, participating in the community’s disaster planning team can coordinate are
disaster planning can provide additional described in the following sections and are
opportunities to ensure the well-being of presented in a checklist in Worksheet B3 (in
the program’s clientele during a disaster. Appendix B).
For example, educating the community’s
disaster planning team on the importance of
appropriate reception into general population State Disaster Behavioral Health
shelters for individuals with behavioral health Coordinator
disorders (FEMA, 2010b) may help avoid An important source for disaster planning
the types of discrimination seen in previous information, support, and coordination is the
disasters (Exhibits 2-4 and 2-5). State disaster behavioral health coordinator;

Exhibit 2-4. Discriminatory Attitudes That Affected Care for People With Mental Disorders
During Hurricanes Katrina and Rita, individuals with psychiatric conditions faced multiple forms of
discrimination. Problems included denial of access to housing and other services and inappropriate and
involuntary placement in jails, emergency rooms, nursing homes, and mental institutions. Group home
residents were removed to new locations without prearrangement or tracking systems in place and
could not be found by family members or their original providers.
People with psychiatric disabilities “encountered enormous problems with general shelters” because
such facilities were “crowded, noisy, chaotic, confusing, and sometimes violent, all inadequate
circumstances for a person with psychosis, anxiety, or depression.” Some special needs shelters
were available, but these were designed for people with medical and physical disabilities and so
were inadequately prepared to support the needs of individuals with psychiatric disabilities. In some
instances, the existence of a special needs shelter was used as an excuse to discriminate against
individuals seeking access to the general shelters, with the result that some people with psychiatric
disabilities were unable to obtain shelter altogether.

Source: National Council on Disability (2006).

Exhibit 2-5. Discriminatory Attitudes That Affected Care for People With Substance Use Disorders
Interviews with employees of opioid treatment programs (OTPs) throughout the Gulf Coast region after
Hurricanes Katrina and Rita suggest that discriminatory attitudes against people with substance use
disorders—particularly those who were receiving dispensed methadone—complicated the ability of
some individuals to receive needed services and compassionate care.
In one community, evacuees who were being transported from a public shelter to an OTP for daily
methadone dosing were required to have an armed police escort on the short bus ride. If officers were
busy attending to other duties, the patients (as well as the staff members who would dose them) had to
wait until an officer became available. In another community, a provider reported that police refused to
allow patients access to the methadone clinic located past a floodlighted area, despite their having a
physician letter stating that they were clinic patients. Networking with social service providers, educating
them about substance abuse treatment, and establishing relationships with them before a disaster
occurs may mitigate discrimination-related problems for clients during or after any such incident.
Source: Podus, Maxwell, and Anglin (no date).

13
Disaster Planning Handbook for Behavioral Health Treatment Programs

this official typically is located in the State to other Federal, State, and local disaster
agency focused on behavioral health (e.g., responding agencies (e.g., the National
Division of Behavioral Health Services, Guard), the coordinator can be a source of
Department of Mental Health). Some States information for the individual treatment
have one person in this role, whereas others program’s management and leaders of the
have two disaster coordinators—one for disaster planning team.
mental health services and one for substance
abuse treatment—sometimes operating out of Following a disaster that exceeds the local
different agencies. For purposes of simplicity, response ability, the State disaster behavioral
the following description is of the combined health coordinator may become involved
position, the State disaster behavioral health in the application for, and distribution of,
coordinator. This coordinator oversees the disaster-related funds. These include any
State’s behavioral health treatment response available State and Federal funds (e.g., those
plans and may work closely with programs available through the Robert T. Stafford
within the State to support coordination of Disaster Relief and Emergency Assistance
efforts in response to disaster. He or she Act) and funds from two programs: (1) Crisis
may also be in the position to offer disaster Counseling Assistance and Training Program
training for programs. Serving as a liaison (CCP) grants, which are funded by FEMA

Exhibit 2-6. Networking To Improve Readiness for Disaster (Example 1)

A behavioral health treatment program reported that it is among the first organizations in its community
to get power back after outages because it is on the same priority electric grid as a nearby hospital.
A drawback to this location is that during an emergency, authorities secure the area surrounding the
hospital for emergency vehicles only. The OTP administrator worked with county government officials
to have OTP staff members designated as emergency responders so that they could be provided
with emergency responder IDs; these staff members now have ready access to the clinic when they
encounter a roadblock. But challenges remain for patients trying to get to the program. After one
hurricane, law enforcement officials set up a roadblock at a nearby intersection, where an officer
demanded that patients show proof they were patients of the methadone program before permitting
them inside the area. The administrator went to the roadblock with her patient list in hand and
confirmed identities for police. “If I didn’t know the [patients] . . . if they were not a name on the list,”
she reported, “they didn’t get in.” To avoid problems of this nature, programs are advised to ask law
enforcement authorities about the circumstances under which access to their facility may be restricted
and to negotiate in advance an access plan for staff and patients.
Source: Podus et al. (no date).

Exhibit 2-7. Networking To Improve Readiness for Disaster (Example 2)

A behavioral health treatment program faced problems with the emergency evacuation traffic
measures that were developed for its community. In an evacuation, the highway becomes a one-way
thoroughfare heading out of town; once a vehicle enters the highway, it cannot exit to local streets.
This presents the risk that clients and staff who are delayed at the clinic to complete dispensing of
take-home medications when the emergency traffic pattern is implemented will be unable to return
home to prepare for the community’s evacuation. To avoid problems of this nature, programs can ask
local authorities for information about possible disaster traffic-control measures and road closures and
ask community traffic planners for guidance on routes around potential roadblocks. However, program
disaster planners should consider the possibility that, in an actual disaster, alternative routes may not be
available and detours can greatly increase travel time, especially if power outages turn intersections with
traffic lights into four-way stops.
Source: Podus et al. (no date).

14
 Chapter 2—Beginning the Disaster Planning Process

and administered by the Substance Abuse disbursed when other State and local resources
and Mental Health Services Administration are unavailable; a Presidential declaration of
(SAMHSA), and (2) SAMHSA Emergency disaster is not a requirement. SERG grants
Response Grants (SERGs). are provided out of SAMHSA discretionary
funds dedicated to a variety of programs, which
CCP grants are made available after the means that SERG funding may not be available
President authorizes an individual assistance when requested (Exhibit 2-8). For this reason,
disaster declaration, under which Federal programs should work with their State disaster
aid can be directed to the provision of behavioral health coordinator in advance of any
professional counseling services, including disaster to identify multiple options for funding
after a disaster (Exhibit 2-9).
financial assistance to State or local agencies or
private mental health organizations to provide such
services or training of disaster workers, to victims SAMHSA’s Disaster Technical Assistance
of major disaster in order to relieve mental health Center (DTAC) supports SAMHSA’s efforts to
problems caused or aggravated by such major prepare States, territories, Tribes, and local
disaster or its aftermath (FEMA, 2007a, p. 47). groups to deliver effective behavioral health
response during disasters. DTAC specialists
CCP-funded projects include crisis counseling, can help a program link with the disaster
education, coping skills development, behavioral health coordinator for its State,
assessments, referrals, and linkages to and they can answer questions and provide
services. The grants provide funds for either guidance on CCP grants and SERG funds.
60 days (Immediate Services Program grants) The DTAC Web site links to a resources listing
of more than 1,500 materials. It is located at
or 9 months (Regular Service Program grants)
http://www.samhsa.gov/dtac. For technical
after the disaster declaration. assistance, contact DTAC at 1-800-308-3515,
or at [email protected].
SERG grants, which constitute “funding of
last resort” for behavioral health services, are

Exhibit 2-8. Program Use of SERG Grants

In 2005, shortly after Hurricane Katrina was declared a disaster by President Bush, the State of Texas
applied for and received $150,000 in SERG funds to provide methadone to patients of OTPs who had
evacuated into the State from Louisiana. These funds went to direct care and not to administrative support
of providers. Three years later, Hurricane Ike hit Texas directly, damaging or destroying many substance
abuse treatment facilities and forcing patients to relocate. Texas again applied for a SERG grant, but as
it was so late in the fiscal year, no SERG funds were available. Some small providers were forced to close.
Other providers worked with the State behavioral health authority to find other funding options.
Source: Chance A. Freeman, personal communication, May 6, 2010.

Exhibit 2-9. Distribution of Financial Aid in Louisiana After Hurricanes Katrina and Rita
Following Hurricanes Katrina and Rita, the Robert Wood Johnson Foundation made funds available to
help with replacement of equipment at substance abuse treatment facilities. These funds were available
through a national nonprofit organization of treatment provider associations, the State Associations of
Addiction Services (SAAS). At that time, Louisiana did not have its own State provider association, so
SAAS passed funds to providers within the State via Louisiana’s Single State Agency (SSA) for substance
abuse services. This coordination was critical to the restoration of treatment services in the State.

Source: Michael Duffy, personal communication, April 21, 2010.

15
Disaster Planning Handbook for Behavioral Health Treatment Programs

State disaster behavioral health coordinators Public Health Department

can serve as liaisons with external emergency
response teams from the U.S. Public Public health departments are first
Health Service Commissioned Corps or responders to incidents that can affect
teams coordinated by National Voluntary public health. Responsibilities of the public
Organizations Active in Disaster (see health department vary by jurisdiction, but
Voluntary Organizations, below). These teams, may include: coordination of the healthcare
which can include behavioral health specialists, system throughout the jurisdiction to ensure
are sent into communities to respond to public continuity of essential functions and to avoid
health crises and national emergencies. In interruption of patient and client care; setup
addition, some State disaster behavioral and operation of alternate medical care
health coordinators are directly responsible facilities or shelters for people who need
for assembling behavioral health disaster medical care; support to healthcare partners
response teams comprising staff members from in resource management and coordination;
programs operating in the State. distribution of medications from the Strategic
National Stockpile; mass vaccination;
Finally, the State disaster behavioral health coordination of disaster advance training for
coordinator may help programs affected by healthcare personnel; and other duties.
disaster obtain precredentialed volunteer
assistance through the Emergency System for National standards oblige public health
the Advance Registration of Volunteer Health departments to coordinate disaster
Professionals. This State-based registration planning with the community’s behavioral
system for volunteer professionals includes health treatment systems (HHS, 2011b).
licensed behavioral health treatment For example, the Capability Standard for
counselors and other clinicians (U.S. Community Preparedness notes that (HHS,
Department of Health and Human Services 2011b, p. 10):
[HHS], 2008).
By engaging and coordinating with emergency
Part 1 of Worksheet B4 (in Appendix management, healthcare organizations (private
B) contains a checklist of topics that and community-based), mental/behavioral health
representatives of the disaster planning providers, community and faith-based partners,
team can address with their State disaster state, local, and territorial, public health’s role in
behavioral health coordinator. community preparedness is to do the following:

• Support the development of public health,

Behavioral Health Treatment Programs medical, and mental/behavioral health
systems that support recovery.
As an initial collaborative step, the disaster
planning team is advised to reach out to • Participate in awareness training with
representatives from other behavioral health community and faith-based partners on how
treatment programs located in the community to prevent, respond to, and recover from
and region. Programs need to collaborate so public health incidents.
that they are prepared to assist each other’s
displaced populations in situations where • Promote awareness of and access to
one of them is unable to provide essential medical and mental/behavioral health
services or has clients who must relocate. resources that help protect the community’s
Such programs can share information and health and address the functional needs
resources on disaster planning and coordinate (i.e., communication, medical care,
participation in the broader community’s independence, supervision, transportation) of
local emergency planning. The State disaster at-risk individuals.
behavioral health coordinator can facilitate
these connections.

16
 Chapter 2—Beginning the Disaster Planning Process

• Engage public and private organizations their efforts with the requirements set forth
in preparedness activities that represent by the State departments of health.
the functional needs of at-risk individuals
as well as the cultural and socio-economic, The public health department’s emergency
demographic components of the community. manager can provide planners from behavioral
health programs with targeted planning
• Identify those populations that may be at assistance and can serve as a link between the
higher risk for adverse health outcomes. programs and broader disaster planning and
incident response efforts. Ideally, behavioral
• Receive and/or integrate the health needs of health treatment programs in a community
populations who have been displaced due to collaborate on initial planning and then
incidents that have occurred in their own or collectively approach the health department’s
distant communities (e.g., improvised nuclear emergency manager for integration into
device or hurricane). the community’s planning activities. Some
States organize public health departments by
Standards in other capability areas (such county, in which case the ideal is a countywide
as Community Recovery and Mass Care) collaboration by programs, for purposes of
also require coordination with providers of working with their health department.
behavioral health treatment services.
Exhibit 2-10 describes how a regional
The health department represents network of healthcare organizations
Emergency Support Function (ESF) #8 collaborates extensively for disaster planning.
(Health and Medical) services at the Local Part 2 of Worksheet B4 (in Appendix B)
Emergency Planning Committee, which contains a checklist of topics that the team’s
exists in every jurisdiction to pursue federally representative can address with the public
directed objectives for emergency planning. health department.
The health department also may represent
behavioral health and medical functions at
the Emergency Operations Center that the Strengthening Emergency Response Through
community would establish during a disaster. a Healthcare Coalition: A Toolkit for Local
Another role potentially played by the health Health Departments is a toolkit to support
development of healthcare coalitions.
department would be to relay requests for
Developed by the King County Healthcare
community assistance from behavioral health Coalition, the toolkit can be accessed at
programs, as needed in a disaster situation. http://www.apctoolkits.com/kingcountyhc.
The public health departments coordinate

Exhibit 2-10. Collaborative Planning by Healthcare Organizations

The King County Healthcare Coalition in the State of Washington is a network of healthcare organizations
(i.e., behavioral health treatment programs, hospitals, nursing homes, adult family homes, surgical centers,
dialysis providers, blood centers, and government agencies involved in public health). The coalition develops
and maintains a comprehensive system that helps ensure coordination, effective communications, and
optimal use of available health resources in response to emergencies and disasters for all hazards.
Since 2005, the coalition has focused on three major initiatives: building infrastructure to support a
coordinated, regional emergency response across the healthcare system; strengthening each healthcare
organization’s continuity plan and emergency preparedness; and developing surge capacity and
capability strategies that address public health service needs during disaster.
The coalition is making plans for alternate care facilities, a regional call center to manage demand for
disaster-related health and medical information, and a health and medical volunteer management
system to provide the staffing required supporting that demand.
Source: Michael Duffy, personal communication, April 21, 2010.

17
Disaster Planning Handbook for Behavioral Health Treatment Programs

Emergency Response Organizations general population emergency shelter that is

more likely to offer a fuller range of support
A good practice is to provide a copy of services (e.g., assistance in transitioning
the program’s facility floor plan to local back to permanent housing). Patients have
emergency responders (e.g., police and a right to expect from general population
fire departments). The floor plan should emergency shelters support services that
indicate the locations of personnel who enable them to maintain their independence
typically occupy the premises. Local in that shelter (FEMA, 2010b). This includes,
emergency responders should be informed among other things, access to medications to
of whether controlled substances (e.g., maintain health, mental health, and function;
barbiturates, methadone) that may require refrigeration for medications; and assistance
special protection during emergencies are that may be required due to cognitive and
stored onsite. If so, the responders should intellectual disabilities.
be informed where on the premises such
substances are located. Additionally, local
emergency responders should be notified Local Office of the Drug Enforcement
as to whether people onsite need special Administration
assistance in exiting the facility. To find the
The local Drug Enforcement Administration
right department for filing a floor plan, call
(DEA) agent monitors and reviews actions
the nonemergency phone number of the police
the program takes in a disaster regarding
or fire department.
controlled substances (e.g., relocating a
In some evacuations, the choice of where to methadone supply to an alternate facility)
take people is made on an ad hoc basis by (see Chapter 5). The treatment program’s
emergency responders (National Council on disaster planning team can inform the
Disability, 2006). A representative of the local DEA agent about the use of controlled
disaster planning team can educate local substances that are prescribed or dispensed
emergency response organizations about: to patients and stored at the facility
(e.g., anti-anxiety medications such as
• The characteristics of the program’s benzodiazepines, central nervous system
residential patients (especially residents stimulants such as methylphenidate
of group homes or other 24/7 residential [Ritalin] for treatment of attention deficit/
treatment programs). hyperactivity disorder, methadone for opioid
dependence). The team also can invite the
• The needs of these individuals during and DEA agent to participate in its disaster
after transport. planning. These actions may expedite
• The types of settings that would be most DEA decisions affecting the facility during
appropriate for them to be taken to when a disaster. The State Opioid Treatment
they are being relocated. Authority can assist in making contact with
the local DEA official.
• The specific locations (such as another
residential treatment program) that have
been pre-arranged to accept patients in an Organizations of Pre-Credentialed
evacuation, if such pre-arrangements have Volunteers
been made (see Negotiate Memoranda of The Emergency System for Advance
Agreement, in Chapter 3). Registration of Volunteer Health
The treatment program can work with Professionals (ESAR-VHP) is a Federal
emergency responders to ensure that in an program through which States and territories
evacuation its patients are not automatically register health professionals who can
routed to special needs shelters, institutions, provide volunteer service in disasters and
nursing homes, or hotels rather than to a public health and medical emergencies.
The program verifies the identification and

18
 Chapter 2—Beginning the Disaster Planning Process

licenses, credentials, accreditations, and • The American Red Cross—A prominent

hospital privileges of each health professional provider of disaster shelter, supplies, and
volunteer so that in a disaster incident the services, including tools for communicating
volunteers can be quickly deployed, across with volunteers and partners in disaster
State lines if needed. conditions. The organization also provides
disaster services training through
The Citizen Corps is a national service certification courses (held online and at
program that mobilizes volunteers for local chapters) for potential volunteers,
emergency preparedness and assistance including medical professionals who may
in recovery after a disaster or terrorist be called upon to assist in Red Cross
attack. The program supports personal shelters.
preparedness planning, provides training,
and coordinates volunteer services. Each • Faith-based organizations, service
community has a Citizen Corps Council fraternities, sororities, and clubs—These
(CCC) to carry out the national program’s often have resources, trained volunteers,
objectives locally. Sponsored by the Office of and facilities to support the response
the Surgeon General and a component of the efforts of disaster teams.
Citizen Corps, the Medical Reserve Corps • Mutual-help and recovery groups or
(MRC) is a grassroots, nationwide network advocates (e.g., self-help groups for
of volunteer medical and public health recovery from mental or substance use
professionals who contribute their skills and disorders, individuals credentialed by
expertise throughout the year and in times of the National Alliance for Medication
community need. Assisted Recovery)—These programs and
people can provide psychological support
In a disaster, assistance from either the to individuals in recovery and affected by
ESAR-VHP or a CCC to the behavioral health disaster.
treatment program would be provided through
the community’s Emergency Operations • Consumer advocacy groups—These can be
Center or through a State coordinator. The helpful in coordinating disaster support
behavioral health program’s disaster planning for particular client populations, such
team may choose to make proactive contact as people with cognitive or intellectual
with these organizations to register its own disabilities (see Prepare Clients for a
staff. If no local MRC unit exists, the disaster Disaster, in Chapter 3).
planning team may want to work with Depending on the type of organization and
community leaders to establish one. the circumstances, a wide variety of help
may be available to those affected by the
disaster (e.g., meals; water; housing; clothing;
Appendix D, Disaster Planning Web
toiletries; grant-writing help; replacement
Resources, provides links to organizations of
pre-credentialed volunteers. furniture and equipment; cleanup and
reconstruction supplies, tools, and labor).
Voluntary organizations may also be able to
provide assistance with medication pickups,
Voluntary Organizations transportation to appointments, contacting
family members, and other specific tasks.
Local nonprofit or nongovernmental groups, Some volunteer groups provide disaster
especially those affiliated with the coalition case management services, which can be
National Voluntary Organizations Active especially helpful for clients with disabilities
in Disaster, can serve as facilitators and including behavioral health disorders
gatekeepers for emergency services. These (Stough, Sharp, Decker, & Wilker, 2010). In a
groups include: disaster situation, assistance from volunteer
organizations would be requested through the

19
Disaster Planning Handbook for Behavioral Health Treatment Programs

ESF #8 lead at the Emergency Operations turned over to staff for dispensing, or are
Center; this is most likely the emergency confiscated).
manager at the local health department (see
• First aid principles for identifying and
Public Health Department, above).
assisting shelter residents who have
Federal guidelines for emergency shelters psychotic symptoms, are in withdrawal, or
call for the inclusion in planning of people have other symptoms of behavioral health
with mental health expertise as well as input disorders.
from people with disabilities, access issues,
or other functional needs (FEMA, 2010b). Vendors and Other Nearby Businesses
The guidelines also recommend that one or The disaster planning team can ensure that
more licensed mental health professionals be contingency plans are in place with suppliers
present in a general population shelter or on of the goods and services that will be needed
call at all times. to respond to disaster (e.g., companies that
provide fuel, water, medications, building
The disaster planning team can meet
supplies, dry ice for refrigeration in case of
with representatives from the voluntary
power outage, vans or buses for evacuation,
organizations that operate shelters (and the
snowplowing service, food services for
mutual-aid groups that work in them) so
residential programs, water damage repair).
that staff and clients of the behavioral health
treatment program can learn how to access Evacuation, sheltering-in-place, and
these shelters under disaster circumstances. mitigation are disaster-related activities that
In addition, such meetings present an are best accomplished in coordination with
opportunity to advocate for client needs and neighboring organizations. Representatives
rights in a shelter setting. Issues that can be of the disaster planning team can meet
addressed include: with nearby businesses to share contact
information, identify resources in the
• Procedures for certifying and credentialing
neighborhood, and develop relationships for
medical professionals and volunteers for
working together in a disaster. It is especially
access to, and providing services in, that
important to coordinate with any businesses
organization’s shelters. (Access to some
located in the same building to facilitate the
shelters may be blocked by security or law
sharing of resources when sheltering-in-place.
enforcement personnel for anyone without
such credentials.)
Media
• Procedures to assist individuals in
obtaining medications prescribed to them. Local radio stations, which can be listened
to even when local electrical power is
• Procedures for enabling clients in
disrupted (e.g., via car or solar radios), can
emergency shelters to meet with treatment
be a powerful resource for coordination.
counselors, recovery advocates, or mutual-
The disaster planning team can request the
help groups.
program’s inclusion in local radio and TV
• Admitting procedures at shelters for emergency listings. For example, local media
people who have psychiatric medications can inform the public of the operating status
or methadone take-home doses in their of the program (e.g., open, closed, delayed
possession. opening, operating in an alternate location).
In a disaster situation that affects more
• Procedures for handling medications (e.g., than the program alone, messages to the
documenting in writing any medications general public should be coordinated with
brought into the shelter that remain the community via the Public Information
in the possession of the individual, are Officer of the community’s Incident Command
System (see Chapter 3).

20
 Chapter 2—Beginning the Disaster Planning Process

Educate the Community About can identify and arrange for opportunities
Behavioral Health Services to teach others (e.g., community leaders,
private and public partner organizations,
An important objective that programs can volunteer agencies, representatives from the
accomplish in making the linkages described faith-based community) about the program’s
above is educating the community about mission, the treatment and recovery services
the special importance of behavioral health the program provides, and the contributions
services in disaster situations. Ideally in the program can make to the community’s
coordination with other local behavioral behavioral health disaster preparedness.
health programs, the disaster planning team Exhibit 2-11 provides an example of mental

Exhibit 2-11. Sample of a Disaster-Specific Prevention Message

Coping With the Gulf Oil Spill—Mental Health Information

Practical advice on how to deal with the effects

the Gulf oil spill can have on your mental health

Intense Feelings Are Expected

Over the years the residents of the Gulf coast have demonstrated remarkable resilience. Individuals,
families, and communities impacted by the oil spill are taking steps to adjust and adapt to the situation.
The reaction to financial and personal stress created by the spill is different for each person. Most may
not need any help, or they may need only a little extra support to help them cope with the change in
livelihood.

Talk About Feelings With Friends and Family

Talking about the way you feel and taking care of yourself by eating right, getting enough sleep,
avoiding alcohol, and getting some exercise can help to manage and alleviate stress.

Take Care of Each Other

Check in with your friends and family members to find out how they feel. Feeling stressed, sad, or upset
is a common reaction to life-changing events. Learn to recognize and pay attention to early warning
signs of serious problems.

Know When To Seek Help

Depending on their situation, some people may develop depression, experience grief and anger, turn
to drugs and alcohol, and even contemplate suicide. The signs of serious problems include:
• Excessive worry.
• Frequent crying.
• An increase in irritability, anger, and frequent arguing.
• Wanting to be alone most of the time.
• Feeling anxious or fearful, overwhelmed by sadness, confused.
• Having trouble thinking clearly and concentrating and difficulty making decisions.
• Increased alcohol and/or substance use.
• Physical aches, pains, complaints.
If these signs and symptoms persist and interfere with daily functioning, it is important to seek help for
yourself or a loved one.

Excerpted from HHS (2010).

21
Disaster Planning Handbook for Behavioral Health Treatment Programs

health information that a behavioral as individuals needing care for other

health treatment program can share with a conditions (e.g., support and medication
community that is recovering from a disaster. for epilepsy, diabetes, heart ailments,
(When called on, the program should make asthma). Information about the program’s
a good-faith effort to fulfill whatever it specific vulnerabilities should be conveyed
has promised to contribute; otherwise, the to community leaders so that, in a time of
program may be less welcome in future disaster, its urgent needs are taken into
collaborative planning.) consideration as community response efforts
and resources are allocated.
One way of educating the community about
behavioral health services is to invite other
community partners to disaster trainings for A valuable contribution that a behavioral
staff and provide the materials, free of cost. health treatment program can make to
community disaster planning is to introduce
This would provide an opportunity to discuss
planning partners to the NIDAMED Resources
the role, mission, and scope of services offered
for Medical and Health Professionals. This
by the behavioral health treatment program, initiative provides resources and information
both in a disaster and in general. A secondary about how providers in primary care settings
goal would be to increase the awareness of can provide: alcohol, tobacco, and drug
individual and community preparation. screening (including an online interactive
drug use screening tool); brief interventions;
The program can share general information and treatment. It is located at http://www.
concerning populations with which it has drugabuse.gov/nidamed-medical-health­
expertise (e.g., adolescents, older people, professionals.
pregnant and postpartum women) and
advocate for consideration of their special
needs in disaster planning. The program Exhibit 2-12 describes the problems that
also can emphasize to local leaders that, occurred because, in advance of Hurricane
during a disaster, individuals needing Katrina, behavioral health treatment
behavioral health treatment (e.g., support programs had not established clear
and medication for mental or substance use procedures with the voluntary organizations
disorders) should have the same priority that operated local emergency shelters.

Exhibit 2-12. Example of Need To Coordinate With Voluntary Organizations

Immediately following Hurricane Katrina, the American Red Cross established a shelter in Baton Rouge,
LA, which housed more than 1,200 people. Officials from Louisiana’s SSA for substance abuse services
met with shelter staff to arrange an opportunity for individuals in the shelter to meet with substance
abuse treatment counselors. SSA obtained permission to set up a booth inside the shelter and planned
to use impaired eye goggles (simulating the effects of substance use) as a novelty item to attract people
to the booth. The staff would conduct screening, brief intervention, and referral to treatment (SBIRT)
as indicated. At 6 a.m.—before counselors arrived at the booth—SSA was contacted by officials from
the Governor’s Office and the State and local police. The officials said that they understood the SSA
planned to conduct urine drug testing on all individuals being housed at the shelter and ordered them
not to do so. This miscommunication occurred because information about the purpose of the booth
was passed along informally among shifts and distorted into a false rumor. The misinformation was
corrected, and staff members were deployed to the shelter. This incident demonstrates that advance
coordination may help avert the miscommunications that can occur when attempting to coordinate
activities in the midst of a disaster.

Source: Michael Duffy, personal communication, April 21, 2010.

22
 Chapter 2—Beginning the Disaster Planning Process

Strong relationships with others in the (potential disasters involving human-made

community also can lay the groundwork for materials and stemming from technological
the sustained support that may be needed— or industrial accidents or negligence), and
over weeks, months, or even years—to help human caused (potential disasters caused by
the program and its clients recover from a human accident, civil unrest, or deliberate
disaster’s effects. action). The scope of a hazard can be
internal (only one location of the program is
affected), local (the program in one locality,
Prepare a Hazard Identification its community, and the local infrastructure
are affected, including nearby hospitals,
and Risk Assessment businesses, and schools), or regional
Once the disaster planning team is formed or national (the hazard affects a broad
and educated regarding its mission and geographical area).
scope and has identified the planning
partners in the community, its first priority All hazards present risks of injury,
is to obtain and review an assessment of psychological trauma (including panic), or
its community’s particular vulnerabilities. death for clients and staff members, as well
Typically, a community already has as health risks to clients who experience
prepared such a document, called the hazard sudden interruptions in care and potential
identification and risk assessment (HIRA) public safety issues if individuals with
or the threat and hazard identification and addiction resort to illegal acts to procure
risk assessment (THIRA). A copy can be drugs. Examples of other hazard-posed risks
requested from the planning team’s contact to behavioral health treatment programs
at the public health department or from include the following:
the community’s emergency manager, if
different. The HIRA identifies the types and • Destruction of property, medications, and
scopes of hazards most likely to occur in the clients’ treatment and billing records
jurisdiction. • Damage to facilities or properties that
make access difficult or unsafe
By using the community’s preexisting
assessment as a foundation, the disaster • Damage to community infrastructure
planning team can make informed decisions including landline telephone service,
about its own priorities for disaster planning, utilities (e.g., water, sewage, electricity),
assess the capacity of the organization and transportation facilities
to respond to such hazards, and plan to
• Disruption in the delivery of supplies (e.g.,
meet any gaps in the ability to respond.
medications, linens, food)
Furthermore, it can plan disaster response
measures that align with other local • Clients unable or reluctant to travel to the
response plans. The HIRA serves as the facility for services
basis of planning disaster responses that
are particular to the region that a program • Staff shortages
serves. It can be included in the planning Program-specific factors can affect the
assumptions section of the basic plan and program’s vulnerability to hazards, as
should be used to determine which hazard- well as its strengths in responding to a
specific appendices are prepared and disaster (Exhibit 2-13). Depending on the
documented in the plan. characteristics of the disaster, a program may
be able to continue operations by relying on
Hazard risks differ depending on their type its resources, or it may need assistance from
and scope. Types of hazards include natural the community or local, State, and Federal
(events related to weather, geography, or governments.
pandemic infectious disease), technological

23
Disaster Planning Handbook for Behavioral Health Treatment Programs

Exhibit 2-13. Examples of Program Vulnerabilities and Strengths in a Disaster

Factor Potential Vulnerabilities Potential Strengths
The program is situated, for example, in a flood The program is situated, for example, on
General plain or in a building that does not meet safety high ground above floodwaters or in an
Location codes. earthquake-proof building.
The program is far from emergency rescue The program is more prepared for self-
Rural
stations, hospitals, and other resources that will reliance because of its relative isolation in
Location
be helpful in a disaster. normal times.
Urban The program faces an overwhelming demand for The program can refer its overflow to
Location services from its populous community. nearby programs.

The program is isolated from or misunderstood The program is well integrated into the
by its community. Cultural barriers separate the community and is connected by cultural
Community community from the program. The community ties. The community is aware of what
does not know what the program would need or the program will need and can offer in a
can offer in a disaster. disaster.
The program is not networked into the local The program has close ties to the
recovery communities. Recovery advocates are recovery community. Recovery advocates
Recovery
not prepared to respond to the needs of the have been prepared and pre-credentialed
Support
program and its clients after a disaster. to offer practical assistance to the
program and its clients in a disaster.
The program is small in terms of staff and The program has sufficient staff and
resources, which puts it at risk of being resources so that in a disaster it can scale
overwhelmed by a disaster and increasing the down yet still provide essential services
chance that it will have to close. The program to clients. The program has enough
Capacity does not have the resources (e.g., reserve fund, resources to survive the disaster and its
inventory, insurance, budgeted line items for aftermath.
disaster response) to endure the disaster period,
absorb losses, and avert closure.

Specify Planning Objectives • Prepare the organization for continuous

and Assumptions provision of essential services to clients
and staff (and affected family members,
The disaster planning team can best focus its whenever possible) during and after a
efforts and avoid working at cross-purposes disaster.
if it establishes planning objectives and if
it bases planning on accurate assumptions. • Plan reengagement strategies, to be
Objectives and assumptions are documented initiated after a disaster is over, for clients
in the basic plan. who have not finished treatment or who
were involved in nonessential services.
Planning objectives are the outcomes that the Each annex to the plan also may include
team seeks to attain by developing a disaster additional objectives. For example, the annex
plan, such as the following: that includes the continuity plan can include
objectives, such as the following (FEMA,
• Minimize hazards and risk of disaster. 2004):
• Ensure the safety of all employees, clients,
and visitors. • Identify essential operation functions, staff
positions responsible for maintaining those
• Promote personal and family disaster functions, and position descriptions.
planning by staff members.

24
 Chapter 2—Beginning the Disaster Planning Process

• Put in place succession planning to • The times of day when staff and clients are
maintain operations if primary positions on the premises and services are provided.
become vacant.
• The quantity and types of medications
• Ensure that operations related to the stored at the facility, especially controlled
continuity of the business are sustainable substances (e.g., benzodiazepines,
for a given number of days. methadone) (see Chapter 5).
• Ensure that operations that have been • The frequency with which client records
shut down because of the disaster can are updated and either printed for a paper
resume within a given time period. filing system or migrated electronically to
a remote computer server.
Planning assumptions are best guesses about
the physical and operating environments that • Recognition that a disaster can occur at
will be in place at the time a disaster occurs. any time and during any shift and can
Examples include: reduce the size of the workforce available
to perform essential functions.
• The amount of time it takes emergency
responders (e.g., police, firefighters, • Recognition that disaster response
emergency medical technicians) to reach relies primarily on the staff preparation,
the facility under normal conditions. equipment, and Memoranda of Agreement
that the program has in place before the
• A typical number of staff, clients, family disaster occurs.
members, and visitors on the premises or
in residence at any one time.

25
Chapter 3—Preparing for Disaster

Once the behavioral health treatment program’s

In This Chapter disaster planning team has been organized, oriented
• Mitigate Risk itself to its tasks, forged connections with community
planning partners, and reviewed risk assessments
• Negotiate Memoranda of (Chapter 2), it can progress to the next important
Agreement preparedness activities. This chapter provides
guidance on risk mitigation, readiness support to
• Designate Personnel To
clients and staff, and other advance planning issues.
Assume Command for
Incident Response
• Prepare Clients for a Disaster Mitigate Risk
• Obtain Client Locator The disaster planning team can help its program avoid
Information discontinuation of essential services by working with
• Encourage Staff To management to prepare the program and its facilities
Make Plans for Personal in ways that will lessen the impact of a disaster
Preparedness when it does occur. Such actions are referred to as
mitigation. These actions are guided by the program’s
• Prepare Staff for Supporting hazard identification and risk assessment (see Chapter
Clients in Disaster 2). Mitigation examples include the following:
• Prepare To Connect
• Making changes to the building and grounds to
Clients to Disaster Case
improve the facility’s capacity to withstand a
Management
disaster. Examples: Secure shelves and appliances
• Ensure Counselor Access to to wall studs to prevent them from falling if
Shelters earthquake is a likely hazard. Clear the facility’s
outdoor property of flammable material and debris
• Prepare for Financial if wildfire is a risk.
Resiliency
• Preparing to shelter-in-place for disasters in which
Worksheets (see Appendix B) it would be either impossible or unsafe for staff and
clients to evacuate. Examples: Identify and prepare
• B5 Sheltering-in-Place a safe room in the basement or interior of the
Checklist building for sheltering from tornado. Ensure that
• B6 Record of Memoranda the space is sufficient to house the average number
of Agreement and Qualified of people (clients, staff members, and visitors) on
Service Organization the premises at any one time. (See Worksheet B5
Agreements in Appendix B.)

• B7 Incident Command • Planning for building evacuation. Examples: Stock

System Positions evacuation chairs or slings and other equipment to
enable swift removal of people who need assistance.
Train staff in the use of this equipment.
• Stocking supplies. Example: Store cots, linens, and
nonperishable food items for emergencies during
which staff members must stay overnight.

27
Disaster Planning Handbook for Behavioral Health Treatment Programs

• Preparing staff and clients onsite for personal Negotiate Memoranda of

disaster response. Example: Stock portable Agreement
bags (personal go kits), one per person at the
facility, that include emergency evacuation In the context of disaster preparedness, a
supplies (e.g., water bottle, flashlight with Memorandum of Agreement (MOA; also called
batteries) (Exhibit 3-1). a Memorandum of Understanding, or MOU),
is a document that defines how one party will
To limit as much as possible the extent to assist another on request. When the agreement
which staff members are affected by any is bilateral or multilateral, the document may
disaster that occurs, the treatment program’s be referred to as a mutual aid agreement. MOA
disaster planning team can identify ways to can be arranged among all programs within
support staff in home disaster planning. Staff a county or State, and they can be arranged
can be directed to Federal guidance for the State-to-State, to plan for disasters with wide
disaster readiness of individuals and families geographic impact. The optimal situation is to
(e.g., preparing a family emergency supply have written agreements prepared in advance
kit, developing a family emergency plan for and reviewed by all parties, either annually or
evacuation and for staying in contact, and when relevant circumstances change (Exhibit
becoming familiar with appropriate actions to 3-4). If needed, they can be arranged after the
take during an emergency). fact (Exhibit 3-5).
Exhibit 3-2 demonstrates the importance of Examples of issues that might be covered in
preventive action to lessen the impact of a an MOA include the following:
disaster, and Exhibit 3-3 contains examples
of mitigation specific to behavioral health • Arrangements for use of alternate facilities
treatment programs.

Exhibit 3-1. Welcome Bags and Personal Go Kits

Our team has created welcome bags for our residential intake clientele that contain toiletries as well as
comfort items such as a blanket, a journal, a deck of cards, a novel or book of meditation, a portable
media player, scented candles, and so forth. We also put clothing (sweat suits and t-shirts—sized at
admission) into the welcome bags of patients who are emergency intakes and have not had time to
prepare for admission. We prepare 20–30 welcome bags at a time so that we always have an adequate
inventory and try to have 10 for each gender on hand at all times. The welcome bags are backpacks
with designated ID tags and space for storage of medication should the need arise for evacuation. We
also store about 40 smaller emergency go kits in the same location. These contain potable water, high-
energy food bars, and other foods with long shelf life, such as dehydrated fruits. The go kits are stored
near the welcome bags to be placed in the backpacks or provided to staff as needed.

Source: Michael Lynde, personal communication, April 26, 2010.

Exhibit 3-2. Preparing for Power Failure

An inpatient behavioral health treatment program in the State of Washington had court-ordered individuals
among its patients. To allow someone to exit through the facility’s doors, a code had to be entered into
an electronic keypad. When the power failed, the doors automatically unlocked—to the surprise of the
program’s administrators—and some of the court-ordered patients nearly escaped. Although the facility had
a generator, the electronic keypads were not connected to it. After this incident, the facility’s staff connected
the electronic door system to the generator and instituted a policy of regular testing.

Source: Michelle McDaniel, personal communication, August 14, 2009.

28
 Chapter 3―Preparing for Disaster

• Agreements to provide essential services • Agreements to support computer system

on a temporary basis to another program’s needs in a move to an alternate location
clients when needed

Exhibit 3-3. Examples of Disaster Mitigation Specific to a Behavioral Health Treatment Program
• Store medications in a safe, locked area that can be protected from the most probable hazards. For
example, programs in flood-prone areas can store medications above ground level, whereas programs
that are in earthquake-prone areas can store medications in cabinets that are secured to an interior wall.
• Maintain a 3-day supply of water, food, linens, garbage bags, sanitation products, and other provisions to
sustain the maximum number of people who may be on the premises at any one time. This includes clients,
staff members, volunteers, and visitors. The supply should include provisions particular to people who may be
on the premises and who are defined as at-risk (U.S. Department of Health and Human Services, 2012) (e.g.,
children, senior citizens, pregnant women, those with chronic medical disorders, those with pharmacological
dependency) as well as provisions for any pets or service animals on the premises. Keep an inventory of these
supplies, and check the expiration dates as necessary to ensure their safety and effectiveness.
• Keep coolers onsite for use when transferring refrigerated medications in an evacuation.
• Ensure that electricity-dependent systems, such as security alarms or water pumps, have battery
backups or are connected to generators that automatically launch if power is lost.
• Ensure and test all means of exit from buildings, such as elevators and stairwells, that may be affected
by power outages.

Exhibit 3-4. Negotiation for Assistance in Hurricane Season

During hurricane season in South Florida, small behavioral health treatment programs in vulnerable
areas, such as the Keys, have evacuation and transfer agreements with larger programs located in
metropolitan areas. Programs evaluate the necessity of evacuating and transferring clients based
on advisory information from local and State officials and from the National Hurricane Center, which
provides information on a continuous basis about the patterns and severity of an approaching hurricane.
Evacuation and transfer agreements are ongoing and include plans for client continuity of care. Most of
the programs’ agreements also include plans for the relocation and transfer of the staff members who
will provide needed services to clients. The objective is to conduct evacuation and transfer at least 24
hours before the predicted landfall of an approaching hurricane.

Source: John Lowe, personal communication, January 8, 2009.

Exhibit 3-5. Negotiation for Mutual Aid Following a Major Snowfall

In winter 2009, the State of Washington experienced an unexpected heavy snowfall—more than 5 feet
of snow fell within a month in some areas. As temperatures rose and snow melted, flood risk increased.
An opioid treatment program (OTP) administrator became concerned that her facility might have to
close temporarily. She contacted an OTP in neighboring King County to arrange for guest dosing of her
program’s methadone patients. This neighboring OTP was a party to a mutual aid agreement (arranged
under the auspices of the King County Healthcare Coalition) that described the terms under which King
County OTPs would provide guest dosing services to one another. The King County OTP used this
mutual aid agreement as a template for a new agreement between itself and the OTP located outside
King County that was at risk of flooding. Fortunately, the patient transfer was not needed, and the two
OTPs now have an agreement in place for future use.

Source: Michelle McDaniel, personal communication, August 5, 2009.

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Disaster Planning Handbook for Behavioral Health Treatment Programs

• Provision of evacuation transportation of health and mental health information; the

assistance Health Information Technology for Economic
and Clinical Health Act; any applicable State
• Lending or borrowing personnel to
privacy regulations).
temporarily fill key staffing gaps (Exhibit
3-6) Organizations with which information
• Payment arrangements for any of the about clients in substance abuse treatment
above may be exchanged in a disaster, but that
are not providers of substance abuse
Other details that typically are covered in a treatment services, should be asked to sign
mutual aid agreement include the roles and a qualified service organization agreement
the scope of responsibilities of each party; (QSOA), as required under 42 CFR Part 2.
procedures for requesting, providing, and Such organizations may include voluntary
ending aid; procedures for reimbursement organizations, local emergency responder
and allocating costs between the parties organizations, and alternate service providers
to the agreement; and communications (e.g., drug testing providers).
compatibility issues (e.g., for running client
record software on another program’s Appendix F includes a sample MOA used by
hardware systems; see Ensure Interoperable OTPs in King County, WA. Other programs
Communications, in Chapter 4). Other topics can use it as a template or can adapt it, as
a mutual aid agreement might cover include needed. Worksheet B6 (in Appendix B) can
mechanisms for invoking and revoking the be used to create a record of all completed
agreement and liability and immunity issues agreements. The disaster planning team can
(National Fire Protection Association, 2007). consult with its State disaster behavioral
health coordinator for advice on drawing up
The mutual aid agreement between behavioral an MOA, including mutual aid agreements
health treatment programs may also cover and QSOAs. Because of the legal implications,
procedures to be used to ensure client privacy programs are advised to consult an attorney
and confidentiality (e.g., as mandated by 42 when negotiating such agreements.
Code of Federal Regulations [CFR] Part 2
[Confidentiality of Alcohol and Drug Abuse
Patient Records]; the Health Insurance
Portability and Accountability Act, which
establishes privacy rules for the protection

Exhibit 3-6. Staff Issues To Consider in Mutual Aid Agreements

Agreements to provide mutual aid for staffing assistance may be helpful, but the ramifications of such
efforts are best explored in detail long before any disaster occurs. An administrator at a program that
experienced an influx of displaced clients after Hurricane Katrina felt that having more staff members
would not have helped. He explained, “We have a limit of space, and we knew what would have to be
done . . . . If you weren’t already working here and [didn’t know] what needed to be done, you’d have
to be trained and we didn’t have time to train.”
An administrator at another program affected by the hurricane was part of a network of clinics and
requested staff assistance from an affiliate. The greatest challenge, he reported, was finding housing for the
guest workers. Three people stayed with the administrator and his family at their small home, and others
stayed with another staff member. “We put them in our own houses and fed them and brought them to
work with us. It was a very difficult time.” Similar challenges occurred at other programs. One provider, for
more than a month, housed several medical volunteers in a motorhome parked outside his house.

Source: Podus et al. (no date).

30
 Chapter 3―Preparing for Disaster

into the hierarchy of the whole community’s

The Emergency Management Assistance disaster response leadership.
Compact (EMAC) is a national disaster relief
compact that facilitates the transfer (within In the ICS hierarchy, the leader of an
or across States) of personnel, equipment, organization is referred to as the Agency
commodities, and services to affected localities. Executive. When a disaster occurs and the
All 50 States, the District of Columbia, Puerto behavioral health treatment program’s
Rico, Guam, and the U.S. Virgin Islands are Agency Executive activates its disaster plan,
EMAC members. Liability, cost responsibilities, he or she appoints an Incident Commander.
credentialing, licensing, and certification issues
Typically, the Agency Executive delegates the
are resolved in advance through the EMAC
Incident Commander role; however, in some
compact. In a disaster, the behavioral health
treatment program would route or receive circumstances the Agency Executive may
resource requests through the State emergency double as Incident Commander, for example,
management agency. Information on EMAC is if the program has a small staff or if the
available at http://www.emacweb.org. effects of the disaster are relatively limited.

During the disaster and in its aftermath,

the Agency Executive focuses on the
Designate Personnel To Assume organization’s essential functions, while the
Command for Incident Response Incident Commander takes charge of disaster
response. The latter independently manages
Federal guidelines for disaster planning response activities (e.g., evacuating the
suggest that organizations follow a premises, coordinating with rescue workers,
management approach called the Incident assessing damage, arranging for temporary
Command System (ICS; Federal Emergency quarters and coordinating transportation to
Management Agency [FEMA], 2007b), which that site, contracting for supplies or repairs)
allows for flexible, appropriate response to any and periodically communicates incident
kind and size of incident and which provides status to the Agency Executive.
common terminology for use by all responders
so that they clearly communicate with each Disaster planning teams are encouraged to
other. As part of the ICS, each organization assign other incident response positions in
names its leaders for disaster response who, accordance with ICS (FEMA, 2007b). The ICS
in a large-scale incident, can readily integrate structure is illustrated in Exhibit 3-7.

Exhibit 3-7. Incident Command System

Agency Executive Incident Commander

Liaison Officer Safety Officer

Public Information
Officer

Planning/ Finance/
Operations Team Logistics Team
Intelligence Team Administration Team

Source: FEMA (2007b).

31
Disaster Planning Handbook for Behavioral Health Treatment Programs

The position of Incident Commander is the

only one that must be filled when the disaster Online courses on ICS, offered through the
plan is activated (FEMA, 2007b). If the Independent Study Program of the Emergency
incident is small in scope or short lived, the Management Institute, FEMA, can be accessed
Incident Commander may choose to retain at http://training.fema.gov/IS.
all responsibility for disaster response. If the
incident is larger or expanding, the Incident
Commander may assign duties to other Prepare Clients for a Disaster
command officers, if they have been appointed
(e.g., Liaison, Public Information, Safety). Psychological distress, severe depression,
somatic symptoms, posttraumatic stress
The disaster planning team should designate disorder (PTSD), and changes in the amount
one or more backups for each ICS position and type of substance use—these are some of
in case the primary designee is unavailable the reactions individuals may have during or
when a disaster occurs or needs to be relieved following disaster. Program clients will vary in
during the disaster response. Large programs their resilience, depending on many interacting
operating in a disaster with significant factors, including an individual’s social
impact may also organize teams for response, supports, previous experience with trauma,
as recommended for an ICS (Operations, preexisting medical and behavioral health
Planning/Intelligence, Logistics, and Finance/ status, gender, ethnicity, and socioeconomic
Administration). status (Cepeda, Saint Onge, Kaplan, &
Valdez, 2010; Cepeda, Valdez, Kaplan, & Hill,
For the behavioral health treatment program, 2010; Cerdá, Tracy, & Galea, 2011; Laditka,
an advantage of organizing personnel into Murray, & Laditka, 2010; Picou & Hudson,
an ICS is that the unambiguous hierarchy 2010; Rhodes et al., 2010; Zwiebach, Rhodes, &
provides for effective management and Roemer, 2010). People with health issues may
accountability. The size of the responding respond more slowly in disaster situations and
group can be changed, depending on may be unable to respond adequately, placing
immediate needs and the scope and duration them at greater risk. They also may be more
of the incident. Another advantage is that susceptible to disaster effects (e.g., extreme
personnel can be readily integrated into the weather conditions or limited food and water
teams of other organizations involved in supplies) (Bethel, Foreman, & Burke, 2011).
disaster response. Young people are at particular risk for negative
mental health effects subsequent to disaster
External response groups (e.g., those headed (Mace et al., 2010b; Murray, 2010).
by a county emergency manager or fire
department) will be organized using the Specific disaster-related factors (e.g.,
ICS structure. For example, the Operations the impact in terms of injury, loss, or
Team of an external response group might be displacement; the passage of time since the
responsible for conducting search and rescue disaster) will influence the behavioral health
or fire suppression. The behavioral health issue that predominates among a program’s
treatment program’s key personnel should clientele. For example, the predominant
be familiar with the names and functions of behavioral health issue for 182 survivors of
ICS positions, in case they are called on to the Oklahoma City bombing 6 months after
interact with external response groups that the incident was symptoms of PTSD; for 421
are organized in this manner. evacuees 2 weeks after Hurricane Katrina,
the issues were preexisting, chronic mental
To clarify how ICS works, a hypothetical and substance use disorders (North, 2010).
example is presented in Exhibit 3-8.
Worksheet B7 (in Appendix B) can be used Even though resilience and need after a
to assign staff members to ICS positions. disaster will vary and cannot be fully predicted,

32
 Chapter 3―Preparing for Disaster

all clients can benefit from preparation. extent possible in a disaster (see Emergency
People are more intentional about preparing Planning for Staff and Clients, in Appendix D).
for disaster when they consider the basic
service interruptions that could occur (Martel
& Mueller, 2011). For this reason, programs Disaster preparedness resources for individuals
and families are available from the National
should be explicit in describing how a disaster
Child Traumatic Stress Network. These
can affect the community at large (e.g.,
include family preparedness tips and family
electrical outages, interruptions in water preparedness wallet cards (for recording
service) and the behavioral health treatment emergency contact information) in English and
program specifically (e.g., closures, reductions several other languages. They can be accessed
in services, services provided at an alternate at http://www.nctsn.org/resources/public­
facility). Programs can educate clients about awareness/national-preparedness-month#q3.
what to do to take care of their own needs to the

Exhibit 3-8. Hypothetical Example of an ICS in Action

An earthquake occurs at 1 a.m., damaging a two-story residential treatment center located on a
major urban thoroughfare. The senior person on staff is the night shift clinical nurse supervisor. Both
the executive director and security officer are at home when the earthquake occurs, and, because of
highway damage, getting to the facility is difficult. Phone and Internet systems are out of service where
the treatment program is located.
The clinical nurse supervisor is aware that although he is third in line to fill the Incident Commander
role (behind the executive director and security officer), he must assume the role because the other two
persons are not onsite. As Incident Commander, he assigns the two custodians on duty to assess the
condition of the building and report back. They report structural damage, so the Incident Commander
orders an evacuation of the building to a safe location—a city park two blocks away.
The Incident Commander assigns the role of Safety Officer to a nurse on duty. Using staff and patient
rosters, the Safety Officer makes sure that everyone leaves the building safely. As the patient roster
indicates, two patients on the upper floor have physical disabilities and cannot use the stairs. It is
inadvisable to use an elevator after an earthquake, so the Incident Commander organizes staff members
to evacuate those patients using evacuation slings. Before permitting this evacuation to proceed, the
Safety Officer ensures that the evacuation slings are in good condition; that staff members are trained,
licensed, and physically able to use the slings; and that the evacuation route is safe.
Shortly thereafter, a fire breaks out on the block, and several fire trucks and ambulances arrive. The head
of the fire squad assumes the role of Incident Commander for the fire incident. The treatment program’s
clinical nurse supervisor maintains the role of Incident Commander for the residential treatment center
and takes on the role of Liaison Officer to coordinate with the emergency responders. He provides the
fire squad’s Liaison Officer with information about the patients under his care, including confirmation
that the building was evacuated and that the residents have been congregated in a safe location
outside the fire zone.
The treatment program’s security officer arrives an hour later, and, after being briefed, she assumes the
Incident Commander role from the clinical nurse supervisor. She directs the clinical nurse supervisor to
retain the role of Liaison Officer, because communication between the treatment center and the fire
department continues to be important.
Based on plans established earlier, the Incident Commander manages the treatment program’s disaster
response. She immediately arranges for patients to be moved to a residential center unaffected by the
earthquake and coordinates the reassignment of staff to the temporary location and the notification of
families with updated information and the status of their family members. The next day, conferring with
the executive director (the Agency Executive, in ICS parlance), she sets in motion the inspections and
repairs needed to restore onsite clinical services.

33
Disaster Planning Handbook for Behavioral Health Treatment Programs

All clients need to know how they will be Members of a client’s support network (e.g.,
informed if the program is closed or has family, partner) also need to be provided
changed its hours of operation and what they with emergency instructions and should be
should do if the program closes or is providing informed as soon as possible of unexpected
services in another location. They also need discharge, evacuation, or relocation. To
to know what they should do if they cannot the extent possible, any evacuations or
access prevention, treatment, or recovery relocations should be coordinated with the
services for several days or if they begin to client’s support network so that the client
experience a physical or behavioral health can be accompanied. Individuals to be
crisis. The program can consider issuing contacted in an emergency should be listed
clients maps that contain directions to the in the client’s records, and appropriate
facility using different routes and modes of authorizations/releases should be in place.
transportation. The map also can indicate
routes to the alternate care facility clients Programs can help clients prepare an
are advised to use if the program is closed emergency health information card, which
(based on a previously developed MOA). lists the client’s special needs and provides
Maps should be in an accessible format for guidance to emergency responders on
the client population (e.g., in large type, in appropriate methods for assisting the
Braille, in languages other than English that person, communicating with the person, and
are prevalent in the community), and they interpreting the person’s behavior. The card
should contain street address, phone, email, allows for fast communication of pertinent
and Web site information. information to rescuers and personnel
working evacuation and shelter sites.
Clients can be informed of the items they
should bring to an alternate site. These may
include the name of their home behavioral The Independent Living Resource Center of
health treatment program and treating San Francisco’s Web site contains a series of
tip sheets on emergency preparedness for
physician, an ID card issued by the program
people with disabilities. These tip sheets can
or other form of personal photo ID (e.g., a be accessed through their publications page
driver’s license), and medications and dosage at http://www.ilrcsf.org/access-resources/
information (see Chapter 5). publications/.

Ideally, the program discusses with clients

the need for disaster preparedness at
intake and at regular intervals during their
treatment involvement (e.g., by reviewing Obtain Client Locator Information
procedures at the start of each hurricane After a disaster, clients may be dispersed
season). Counselors can provide clients from their regular residences and
with instructions for self-care related to surroundings. The program’s efforts to locate
their behavioral health disorder treatment clients after a disaster, and to reengage them
(on a laminated wallet-sized card, for in services, can be facilitated by collecting
example). They also can direct clients to sufficient contact information at intake.
disaster preparedness planning information The disaster planning team can work with
for individuals and families. The program staff responsible for the program’s intake
can prepare in advance a recorded phone form to ensure that sufficient emergency
message, to be used in a disaster situation, contact information is collected and regularly
providing instructions to clients on what to updated.
do if the program is closed. These emergency
instructions also can be readied for posting Ideally, the intake form requests the
on the facility’s front door and to social media following: client contact information (e.g.,
Web pages. address, landline, cell phone, email, social

34
 Chapter 3―Preparing for Disaster

networking Web sites); emergency contact

information for one or more relatives, friends, The American Red Cross has developed a series
or professionals with whom the client of mobile apps that provide users with real-time
interacts (e.g., employer, probation officer, information on what to do before, during, and
mutual-help group sponsor); and an out- after emergencies. They are available at http://
of-area point of contact. Locations that the www.redcross.org//prepare/mobile-apps.
client frequents can be noted on the form,
if this information is available. A physical
description or photo of the client also can be
helpful. The form should have a place for the
Prepare Staff for Supporting
client’s signature indicating that release of Clients in Disaster
the information is permitted for purposes The disaster planning team can arrange for
of tracking the client for reengagement. staff trainings that address disaster-related
Counselors should explain the intent behind behavioral health topics (e.g., recognizing
the form. This discussion can be used as symptoms of psychological trauma in clients,
an opportunity for introducing the topic of referring such clients to psychological first
disaster preparedness. aid services provided in the community,
supporting clients’ coping skills, conducting
Client locator forms are used by researchers
trauma-informed therapy). Training may
to find subjects from a study for follow-up be valuable not only for direct service staff
interviews. Such forms can be used as models members, but also for administrative staff
by the behavioral health treatment program members, particularly those who answer
wanting to supplement its intake form with phones or greet clients at the entrance. An
enough information to find clients who ideal approach is to provide live, in-person
may be displaced in a disaster situation. An disaster training, in which the trainers can
example of a client locator form is provided focus on the roles of the participants and how
in Staying in Touch: A Fieldwork Manual of disaster may affect their jobs. Live training
Tracking Procedures for Locating Substance also allows for discussion of topics that are of
Abusers in Follow-up Studies, published by the particular concern to staff. Live training can
University of California, Los Angeles Integrated
be supplemented by further online training
Substance Abuse Programs. The manual
can be found at http://www.uclaisap.org/
as appropriate (such as for yearly refresher
trackingmanual/manual/Tracking-Manual.pdf. training).

The Substance Abuse and Mental Health

Services Administration’s (SAMHSA) Disaster
Encourage Staff To Make Plans for Behavioral Health Information Series provides
themed resource collections and toolkits
Personal Preparedness pertinent to the disaster behavioral health
Staff members should be strongly encouraged field on topics such as psychological first aid,
to develop emergency plans for their own resilience, and stress management. They are
households. Having personal plans in place available at http://www.samhsa.gov/dtac/dbhis/.
has personal benefits for staff members and
their families and increases the likelihood
Exhibit 3-9 provides psychological first
that they will be available to respond to their
aid recommendations for first responders
professional duties.
(emergency and disaster response workers).
These recommendations may be shared with
Information on personal preparedness is behavioral health treatment program staff
available at a FEMA-sponsored Web site, members so that they are sensitive in their
http://www.ready.gov. initial contacts with clients after a disaster.

35
Disaster Planning Handbook for Behavioral Health Treatment Programs

Programs may wish to provide training to disaster response team, or available to assist
clients to support peers in disaster other staff in working with clients under
preparedness and in coping after disaster. disaster conditions, provides an additional
Some programs already use peer resource for the program.
professionals as part of their staff. Having
these individuals trained as members of the

Exhibit 3-9. Psychological First Aid

Promote Safety:
• Help people obtain emergency medical attention.
• Help people meet basic needs for food and shelter.
• Provide repeated, simple, and accurate information on how to meet these basic needs.

Promote Calm:
• Listen to people who wish to share their stories and emotions; remember that there is no right or
wrong way to feel.
• Be friendly and compassionate even if people are being difficult.
• Offer accurate information about the disaster or trauma, and the relief efforts underway, to help
victims understand the situation.

Promote Connectedness:
• Help people contact friends and loved ones.
• Keep families together. Keep children with parents or other close relatives whenever possible.

Promote Self-Efficacy:
• Give practical suggestions that steer people toward helping themselves.
• Engage people in meeting their own needs.

Promote Help:
• Find out the types and locations of government and nongovernment services and direct people to
those services that are available.
• When they express fear or worry, remind people (if you know) that more help and services are on
the way.

Do Not:
• Force people to share their stories with you, especially very personal details.
• Give simple reassurances like “everything will be okay” or “at least you survived.”
• Tell people what you think they should be feeling or thinking or how they should have acted earlier.
• Tell people why you think they have suffered by alluding to victims’ personal behaviors or beliefs.
• Make promises that may not be kept.
• Criticize existing services or relief activities in front of people in need of these services.

Excerpted and adapted from SAMHSA (2005).

36
 Chapter 3―Preparing for Disaster

clients) may find them inconvenient, they

Information on training individuals with are important practice for evacuation in an
behavioral health disorders to provide peer emergency, and especially for safe and efficient
support in and after a disaster is available evacuation of clients with mobility issues.
from After the Crisis, a collaborative initiative
between the National GAINS Center and the
National Center for Trauma Informed Care and Clients With Limited Literacy, Limited
supported in part by SAMHSA. Information is English-Language Proficiency, or Cultural
available at http://gainscenter.samhsa.gov/atc. Differences
Disaster-related messages (e.g., evacuation
Staff may need to be prepared to give extra instructions, phone and Web site messages
support to certain groups of clients. These about facility closures, instructions to clients
groups, and the support that can be provided to on accessing treatment during a disaster)
them, are detailed in the following paragraphs. should be tested with clients who have
limited reading ability. Messages should be
Clients With Cognitive or Intellectual provided in the client’s primary language,
Disabilities if possible, and in a manner appropriate to
the client’s culture. Program staff should
Disaster preparedness education may need be instructed not to assume that clients are
to be simplified, provided through multiple literate and can follow written directions.
means, and repeated frequently. Clients Key messages should be presented orally and
may need individual support when being frequently. The disaster planning team may
unexpectedly discharged, evacuated, or wish to consult with community members
transferred. Counselors also may need to work who have expertise in the cultural attitudes
with surrogate decisionmakers (e.g., a client’s and languages of clients to ensure that
parent, other family member, guardian) to disaster planning concepts and instructions
plan and prepare clients for disasters. The are effectively communicated. Interpreters
program can recommend clients with cognitive can be included in disaster planning and
or intellectual disabilities for priority disaster exercises. Disaster-related communications
case management by organizations that with clients may be enhanced when staff
provide that service (see Prepare To Connect members have received training in cultural
Clients to Disaster Case Management, below). competency. Exhibit 3-10 illustrates the
challenges in disaster preparation for clients
Clients With Mobility Issues with limited English proficiency.

Clients may need special help and assistive

devices during building evacuation and
Developing Cultural Competence in Disaster
relocation, especially if the program is Mental Health Programs is a SAMHSA-
located on upper floors of a building. Such published guide that can help States and
clients should be informed in advance of communities plan, design, and implement
the evacuation methods that will be used culturally competent disaster mental health
to help them exit the premises (e.g., the use services for survivors of natural and human-
of wheelchairs, gurneys, evacuation slings, caused disasters of all scales. The guide is
two-person hand carrying). Regular safety- one component of the SAMHSA Disaster Kit,
related drills (e.g., for response to fire, bomb which includes a range of materials for disaster
threat, chemical hazard; loading people in recovery workers. Other items in the kit include
wheelchairs onto buses) provide opportunities brochures for distribution to the general public
and guidance on dealing with the stress of
for clients and staff to become familiar with
disaster response. The kit can be ordered or
any special evacuation plans and methods.
downloaded from SAMHSA at http://store.
Such drills are required by all licensing samhsa.gov/product/SMA11-DISASTER.
and credentialing bodies. Though staff (and

37
Disaster Planning Handbook for Behavioral Health Treatment Programs

Exhibit 3-10. Challenges in Disaster Preparedness for Clients With Limited

English Proficiency

Shiu-Thornton, Balabis, Senturia, Tamayo, and Oberle (2007) studied disaster preparedness for clients
with limited English proficiency by interviewing 38 medical interpreters representing 30 languages. The
researchers found that few interpreters had training in disaster preparedness or direct experience with
interpreting in disaster situations. Furthermore, many cultural groups do not discuss the potential for
disasters or engage in discussions concerning disaster preparedness, and some cultural groups have
beliefs that are dissonant with the concept of preparedness. Disaster may be a taboo topic, group
members may believe that events are predestined or in the hands of fate, or they may believe that the
United States is a safe haven where disasters do not occur.

Clients Who Are at Risk of Acute Episodes advised to keep a copy on their person when
of Psychiatric Illness relocating in disaster.

A psychiatric advance directive (PAD) may

provide some measure of protection for clients The National Resource Center on Psychiatric
who could become destabilized in a disaster. Advance Directives provides information about
A PAD is a legal document, accepted in PADs. How-to instructions, State requirements,
most States, through which an individual and other forms can be downloaded from
can indicate preferences and instructions http://www.nrc-pad.org.
for treatment of behavioral health disorders
at times when he or she is not competent
to express his or her own wishes. Through Children and Youth
a PAD, individuals can assign power of
attorney to the person of their choice to Young people’s positive coping can be
make decisions about care when they promoted by sharing age-appropriate
themselves are incapacitated. PADs can information about disasters, before they
include instructions on refusal or consent occur (Murray, 2010). The information can
regarding hospital admission, particular include what to expect before, during, and
medications, and treatments. PADs also can after a disaster incident. The opportunity to
contain other important information, such ask questions is also important. Families of
as guidance about the type of care that could young clients can be encouraged to develop
help the individual avoid hospitalization (or, a family response plan, to include younger
if hospitalization is needed, accommodate family members in making preparations
to it). A PAD is used to guide healthcare (e.g., in assembling the family’s go kit),
decisions only when an authority (one or and to periodically review and discuss
more physicians or a judge, depending on their response plan with family members.
the State) determines that the individual Parents and caregivers of children and
lacks capacity to make decisions. Treatment youth can be directed to resources that will
program counselors can assist clients in help them develop a family response plan
understanding PADs and drafting PADs that and prepare their young family members
are accepted in their respective State. They (see Emergency Planning for Staff and
also can assist clients in distributing copies Clients, in Appendix D).
of their PADs to their treatment program,
medical doctor, local hospital (for filing in As previously stated, any evacuations or
their medical records or inclusion in their relocations should be coordinated with the
electronic health record), and reliable friends client’s support network so that families
or family members. Clients also can be and significant others become aware of
these plans and have a way to contact
the client once they are relocated. To the

38
 Chapter 3―Preparing for Disaster

extent possible, family members should be Clients Who Are Experiencing

kept continuously informed of changing Homelessness
circumstances. Young people in residential
treatment, along with their families, may People who do not have a residence are
need extra help with any transitions of care less able to prepare for emergency (e.g.,
to alternate providers or locations, to reunite stockpile supplies, identify a safe part of
as needed, and to handle the psychological a house in which to shelter). In addition,
effects of the disaster. Efforts should be people without a home may have limited
made to provide youth-oriented treatment access to electronic means of communication
services and supports at any new location (e.g., TV, radio, Internet) and thus may be
(e.g., separate group meetings for youth slower to learn about emergency warnings
and connecting relocated young clients with and calls for evacuation. Furthermore, for a
clinicians who have training and experience variety of reasons, people who do not have a
working with that age population). Youth home may have difficulty or concerns about
may need assistance transitioning to a new entering shelters, and they also may have
school if the disaster has forced a transfer, more difficulty transitioning out of shelters,
and they may need activities to keep them especially if the locations where they formerly
safely occupied if schools are closed. Despite took refuge (such as an encampment) are
changed conditions, effort should be made to no longer habitable (Edgington, 2009).
promote an atmosphere of normalcy (Mace et Behavioral health treatment programs can
al., 2010a). support clients known to be experiencing
homelessness by making sure they receive
disaster planning education and aids
Pregnant Clients or Clients With (e.g., emergency kits, emergency health
Dependents information cards). In addition, the program
can request that its outreach workers be
Pregnant clients will need to be closely
included in the local community’s emergency
monitored to ensure that they can maintain
notification systems so that they can be
a healthy pregnancy despite disaster
mobilized in a timely manner to communicate
conditions; they may need extra counseling
emergency situations to clients who are
on disaster-related medical treatment that
experiencing homelessness. The program also
best protects them and their fetuses (see
can recommend clients who are experiencing
also Exhibit 6-1, Pregnant Women at Special
homelessness for priority disaster case
Risk From Influenza, in Chapter 6). Patients
management by organizations that provide
who have children with them in residential
that service (see Prepare To Connect Clients
treatment and who are relocated will need
to Disaster Case Management, below).
to be transferred to like facilities that enable
the children to stay with them. The facilities
will need to be ones that can provide a safe Older Clients
and secure environment for those children,
with access to child care or schools as Factors that can cause some older clients to
appropriate. Some clients may be unwilling be particularly vulnerable in disaster include
to disclose their behavioral health disorder physical frailty, chronic illness, cognitive
treatment needs to care providers at a new impairment (including impaired capacity to
location for fear of losing custody. These make decisions and execute tasks), mobility
clients need to be educated in advance about and sensory issues, reliance on devices
how to advocate for their needs without such as hearing aids and glasses, limited
risking custody. transportation options, and susceptibility
to exploitation and abuse (Cloyd & Dyer,
2010). Other age-related factors that may
interfere with clients obtaining necessary
aid include a preference for self-reliance,

39
Disaster Planning Handbook for Behavioral Health Treatment Programs

difficulties navigating bureaucratic recovery DCM Program’s guidelines as among the

systems (especially those that require needs that can be addressed by disaster case
online applications and other computer- management services.
related tasks), and concerns about loss of
entitlements. Among older adults, disaster A representative of the behavioral health
response may manifest itself in physical treatment program’s disaster planning team
rather than psychological distress (Sakauye can contact the local office of emergency
et al., 2009). Staff training on the particular management to determine whether the
needs of older clients, as well as coordination community has a disaster case management
with community services for older adults, can program equipped to provide services to
facilitate support to this client population in clients with behavioral health issues and, if
disaster. so, how to refer clients to it. In addition, the
program can seek to work with Voluntary
Organizations Active in Disaster (VOADs)
Clients on Medications whose case managers have expertise with
Assisting clients who are on prescription the issues of its clientele (e.g., issues related
medications is covered in Chapter 5. to disabilities or mental or substance use
disorders).

The disaster planning team may want to

Prepare To Connect Clients to work with its program’s management to
Disaster Case Management train counselors in providing disaster-specific
People affected by disaster often face a case management and to develop a list of
“challenging service labyrinth” as they seek community resources to which counselors can
to recover housing and other resources refer clients for disaster recovery support.
(Stough et al., 2010). The process can be Alternatively, the team can work with
especially complex and difficult for people program management to develop policies for
with psychiatric disabilities who, in past identifying and prioritizing clients for referral
disasters, have faced discrimination with to disaster case management, if such services
regard to evacuation, emergency shelters, will be available from other community
and relief services (National Council on providers.
Disability, 2006).

Some jurisdictions have plans in place Ensure Counselor Access

for providing citizens with disaster case to Shelters
management (i.e., personal assistance in
navigating recovery services). In an event During Hurricane Katrina, situations
that is declared a major disaster by the occurred in which professional counselors
President of the United States and that and members of mutual-help groups (e.g.,
meets other criteria, the Federal Disaster Narcotics Anonymous, Alcoholics Anonymous)
Case Management (DCM) Program may were prohibited from entering shelters to
rapidly allocate funding for disaster assist evacuees in need of behavioral health
case management assistance to disaster treatment services (SAMHSA, 2009). As a
survivors. Funds are administered by the result, Federal guidelines for emergency
Administration for Children and Families, shelters now call for the inclusion in planning
U.S. Department of Health and Human of people with mental health expertise as well
Services, and the case management services as input from people with disabilities, access
are offered via existing State, local, and issues, or other functional needs (FEMA,
voluntary programs (Lavin & Menifee, 2009). 2010b).
“Mental health issues” and “medication
management” are specifically cited by the

40
 Chapter 3―Preparing for Disaster

The disaster planning team leader can work access emergency Medicaid. Programs that
to arrange for the program’s counselors and provided outpatient counseling by telephone
recovery advocates to participate in local as a substitute for in-person sessions
shelter planning and to become credentialed had mixed results in obtaining insurance
for shelter staffing. The disaster planning reimbursement.
team also can encourage program staff
members and community recovery advocates This experience suggests that behavioral
to take the advanced training and obtain the health treatment programs should consider
credentialing that would allow them inside how they can support client retention through
shelters and at evacuation departure and active outreach following a disaster. Program
receiving sites. A working relationship with staff members should become informed
the American Red Cross and other VOADs, about procedures for enrolling clients in
through the community’s emergency planning Medicaid under emergency conditions, and
committee, can facilitate these arrangements they should educate payers about modified
(see Chapter 2). counseling services (e.g., telephone or Web-
based counseling) that may be instituted in
disaster situations; this may help facilitate
Prepare for Financial Resiliency reimbursement. Management can establish
a contingency or reserve fund or a line of
A study of 15 substance abuse treatment credit for unexpected cash flow issues (e.g.,
programs affected by the September 11, maintaining payroll for staff when billing is
2001, attacks in New York City found that disrupted).
several programs experienced financial
losses following the disaster (Dewart, Frank, Programs also can make plans for
Schmeidler, Robertson, & Demirjian, 2003). persevering through a period of low revenue
Outpatient programs were particularly following a disaster (e.g., planning ahead for
affected because of declines in client emergency grant proposal writing, temporary
attendance and retention. Of the 15 programs modification of fees, intensive marketing
surveyed, the 3 that closed on the day of and outreach, expansion into community
the attacks and in the days afterward were disaster-specific behavioral health response
outpatient treatment programs (not OTPs). and support activities, careful tracking and
Fewer financial problems were experienced documentation of services provided during
by programs with substantial numbers the disaster so that reimbursements are
of clients on Medicaid or clients able to facilitated).

41
Chapter 4—Continuity Planning

This chapter addresses the tasks required to ensure

In This Chapter business continuity, commonly referred to as
• Identify Essential Functions continuity of operations planning or COOP planning.
• Identify Essential Staff A continuity plan can be included as a functional
annex to the basic plan. Chapter 5 provides additional
• Provide for Continuity of
guidance on continuity planning for programs that
Leadership
manage prescription medications for treatment of
• Arrange for Alternate behavioral health disorders.
Facilities
• Ensure Interoperable
Communications Identify Essential Functions
• Protect Vital Records and
Databases To identify the program’s essential functions, the
disaster planning team first works with management
• Develop Resources To Manage
to inventory all functions performed at the facility.
Human Capital
From this comprehensive list, the team and
management work together to identify those functions
Worksheets (see Appendix B)
that are essential because they provide vital services
• B8 Identify Essential to clients; are required by regulation or law; are
Functions required to maintain onsite safety for clients, family
• B9 Identify Essential Staff members, and staff members; or are necessary for
Positions the performance of other essential functions (Federal
• B10 Essential Staff Roster Emergency Management Agency [FEMA], 2004).
• B11 Checklist for Continuity
These essential functions should be prioritized by
Planning
potential consequences if the function is not performed
• B12 Requirements for or is delayed. Exhibit 4-1 provides examples of
Alternate Facilities what a program might decide are its essential and
• B13 Alternate Facility nonessential functions. (Note: Each program makes its
Arrangements by Disaster own determinations of what is essential.) Worksheet
Scenario B8 (in Appendix B) can be used to help identify
• B14 Checklist for Relocation essential functions.
Planning
Exhibits 4-2 and 4-3 provide examples of programs
• B15 Checklist for
that worked to continue essential operations during
Maintaining Communications
winter storms.
With Essential Groups
• B16 Checklist of Records
and Databases To
Ensure Interoperable Identify Essential Staff
Communications Once essential functions have been identified, the
• B17 Checklist for Protecting disaster planning team continues to work with
Records and Databases program management to identify the staff positions
• B18 Checklist for Managing required to perform those essential functions.
Human Capital The team and management also work together to
identify the specific individuals who can serve in

43
Disaster Planning Handbook for Behavioral Health Treatment Programs

Exhibit 4-1. Examples of Essential and Nonessential Functions

Program Nonessential
Essential Functions
Type Functions
• Provide for the physical safety of all clients and visitors at the facility. • Perform
• Provide behavioral health emergency services. extended intake
and discharge
• Conduct basic screening, intake, and discharge procedures. procedures.
• Track clients affected by dispersal and evacuation to ensure they • Conduct
continue to receive needed behavioral health services. nonmandated
• Provide crisis and relapse prevention counseling; ensure that some drug testing.
support is available to clients. • Offer routine
• Assist clients in accessing needed medications. counseling and
• Conduct drug testing for mandated clients. education.

• Adhere to applicable State licensing standards. • Provide general

mental and
All Programs • Maintain treatment and billing records in accordance with payer and substance
regulatory requirements. use disorder
• Document transfer of clients and their records to another provider. prevention
• Protect client rights and privacy, including the integrity of protected services.
health information records.
• As resources are available and based on mandates, provide disaster
mental health services to the community as requested by the
Emergency Operations Center or Emergency Support Function #8
Coordinator.
• Provide prevention guidance specific to the present disaster to
reduce the likelihood of traumatic stress in the program’s clientele
and other members of the local community.*
• Assist with case management activities such as linking to resources, • Provide regular
including helping clients obtain replacements or refills, as outpatient
appropriate, for needed medications. services.
Outpatient • Provide crisis stabilization, crisis intervention, or other emergency • Host onsite
Treatment services to outpatients. mutual-help
Programs group meetings.
• Donate meeting
space for
community groups.

• Provide residential care for patients who do not meet discharge criteria. • Provide residential
• Stabilize patients undergoing nonmedical (social) detoxification care for patients
(see section below for essential functions of a program providing who can be
medically managed detoxification). discharged.

Residential • Continue medications and supportive counseling to patients to

Treatment prevent decompensation or escalation of symptoms of behavioral
Programs health disorders.
• Coordinate or address transportation needs for accessing medical
services.
• Provide case management services, as appropriate, to move patients
toward discharge readiness.
* Public messages in disaster should be coordinated with the Public Information Officer of the community’s Incident Command System
(see Chapter 3).

44
 Chapter 4—Continuity Planning

Exhibit 4-1. Examples of Essential and Nonessential Functions(continued)

Program Nonessential
Essential Functions
Type Functions
• Follow established medically managed detoxification protocols. • Medically detoxify
• Medically stabilize patients; closely monitor patients’ withdrawal patients who
Medically
symptoms. can be safely
Managed
transferred to
Detoxification • Transfer patients who require a higher level of medical care than the
and detoxified in
Programs program can provide to an appropriate facility; provide residential another setting.
care for patients who remain at the facility.

• Confirm identities and dose information for patients receiving • Provide other
medication. case management
Opioid services beyond
Treatment • Provide or facilitate access to prescribed or dispensed medications
(e.g., methadone, buprenorphine). those determined
Programs essential.
(OTPs) • Provide case management to assist with medically appropriate
transfer or discharge.

Exhibit 4-2. Essential Operations Continuity During a Winter Storm (Example 1)

A major winter storm stranded residential program staff members in their homes and resulted in on-duty
staff extending their shifts to nearly 72 hours. Travel was not advised, and access to the interstate highway
was closed. Food was not an issue because the program had stored a 2-week supply of provisions.
The program had recently purchased and implemented a Web-based client management system that
clinical supervisory staff could access from home to create and modify treatment plans that could be
implemented by clinical staff. This system allowed staff to document client progress and medical updates
with no interruption to client services.
During the storm, assigned therapy sessions had to be rescheduled or canceled because some therapists
could not get to work. The onsite team had to be creative, and the program assumed a comfortable
“retreat” atmosphere as the staff took this opportunity to work with clients more deeply on specific group
topics. It was decided afterward to plan a series of mini retreat activities as “off-the-shelf” options, for use
in future incidents when the program is short staffed because of emergency.

Source: Michael Lynde, personal communication, May 3, 2010.

Exhibit 4-3. Essential Operations Continuity During a Winter Storm (Example 2)

An outpatient treatment facility was hit hard by an unexpected snow and ice storm. The emergency
preparedness plan was initiated. A few staff members who had computer access at home worked
throughout the day providing phone counseling and documenting those client services in the
client record electronically. Phone services included triaging counseling emergencies, rescheduling
appointments, and providing supportive recovery counseling to clients and family members, as well as
counseling to relieve any mild anxiety caused by the storm. Client care continued throughout the storm.

Source: Kathyleen M. Tomlin, personal communication, May 1, 2010.

45
Disaster Planning Handbook for Behavioral Health Treatment Programs

those positions. Such people must have care so that they can report as needed for
the knowledge, skills, and abilities for the duty.
designated roles, as well as the required
certifications and licenses. Some personnel Management can work with staff members
may be able to assume the essential duties who usually perform an essential function to
of multiple staff positions. The credentials develop a written plan for maintaining that
and State licenses of essential staff should function in a disaster situation. The planning
be scanned and saved electronically, in case team can assemble these plans together
this documentation is needed at an alternate into the continuity plan functional annex.
location or receiving facility (see Protect Worksheet B11 (in Appendix B) lists some
Vital Records and Databases, later in this questions to be addressed as the team drafts
chapter). Essential function status should be the continuity plan.
included in job descriptions and expectations
communicated to employees.
Provide for Continuity
In a disaster situation, only essential staff
members would report for work onsite or in
of Leadership
the new location (if the facility has moved); Leadership is essential in a disaster, so
other available staff members would be alternate leaders need to be identified in
directed either to stay at home or to be advance for situations in which personnel who
available to work on a rotating schedule. normally exercise authority are incapacitated
The goal is to assemble a roster of the or unavailable. For each such position,
minimum number of people who together management must approve the order of
can perform all essential functions. Multiple succession and the delegation of authority.
backups for all positions should be assigned
in case the designees are unavailable or
have been called away to serve in behavioral Order of Succession
health response efforts. Worksheets B9 An order of succession officially passes
and B10 (in Appendix B) can be used to authority from one person to another.
complete this task. Depending on the size of the facility and staff,
several successors may be named for each
To facilitate the development of an essential position; multiple successors are especially
staff roster, the team can ask the program’s important for the pandemic influenza
management to prepare staff members for scenario (see Chapter 6). If possible, the
the possibility that, in a disaster situation, order of succession should include successors
they will have to perform additional duties who work at different facilities in the event
or work under changed schedules. Staff all leaders at one facility are incapacitated.
members need to be briefed regarding the Examples of order of succession for leadership
scope of their responsibilities as outlined in positions at a behavioral health treatment
the disaster plan, and they need to be willing program are provided in Exhibit 4-4.
to carry out those duties (e.g., a mental
health services provider may be asked to
pass out blankets and water bottles when Delegation of Authority
speaking to people who have been evacuated A delegation of authority describes the
into a shelter). Expectations related to permissible range of actions for each
reporting to work during a disaster can leadership successor. The scope of authority
be clearly stated in policy, included in job can be determined in advance for each named
staff descriptions, and covered in annual successor, based on his or her qualifications.
reviews. Staff members also can be assisted For example, if the executive director is not
in creating plans, in advance, for dependent on duty when a disaster occurs that calls
for immediate evacuation, a successor may

46
 Chapter 4—Continuity Planning

Exhibit 4-4. Examples of Order of Succession at a Behavioral Health Treatment Program

Leadership Position Example Order of Succession
1. Assistant director
Executive Director/
2. Clinical director
Administrator
3. Clinical nurse supervisor
1. Clinical nurse supervisor
Clinical Director 2. Clinical nurse
3. Senior licensed counselor or program manager
1. Staff physician
2. Advanced registered nurse practitioner (or other staff member with
Medical Director or independent prescriptive authority)
Chief Psychiatrist 3. Certified physician assistant (or other staff member with independent
prescriptive authority)

assume authority to make decisions about the sufficient space, equipment, supplies, and
move and, through prior arrangement, have support services so that staff can perform
the authority to expend funds for transport. essential functions (FEMA, 2007c). Other
Authority can be limited so that the considerations include whether the proposed
successor cannot make decisions about long- facility has the necessary compatible
range matters. Once the executive director communications and computer systems
resumes leadership, the successor’s delegated infrastructures to maintain essential services
authority is terminated. and is capable of meeting food, lodging,
health, sanitation, and security needs of
essential staff and clients either onsite or
Arrange for Alternate Facilities nearby. Some programs may already have
offsite hosting of software supporting various
The program’s disaster planning team can functions, including electronic records. This
research several options for continuing may provide an advantage in the case where
essential operations elsewhere. These options relocation of these functions is necessary.
would be considered by leadership, and
the program director could authorize them Each disaster planning team makes its
through Memoranda of Agreement with own determination of criteria for alternate
alternate facilities. When a disaster occurs, facilities. For example, in addition to meeting
a displaced program can move to the most the criteria identified above, the team may
practical prearranged alternate facility, look for an alternate facility that is licensed
given the circumstance (e.g., another space by the State authority, as required (e.g., for
within the building, another location of the an alternate residential, opioid dependence,
organization, space that is borrowed from or child and adolescent treatment program).
or shared with another organization in the Another feature the team may seek is space
community, a site that is miles away or out of that can be configured for providing essential
State). services (e.g., a client waiting room, private
rooms for counseling, large space for group
The team should evaluate alternate facilities therapy) and that has necessary furnishings
and suggest to leadership multiple options. (e.g., beds for residential services, tables
For each option, the team should consider for serving meals, chairs for group rooms,
whether the prospective alternate facility is secured storage area such as lockable file
located at a safe distance from the area— cabinets). Other features to consider are
such that it would not be compromised by whether the alternate facility is physically
the hazard that forces relocation; can be accessible under Americans with Disabilities
made operational in 12 hours or less; and has Act of 1990 requirements, is affordable (in

47
Disaster Planning Handbook for Behavioral Health Treatment Programs

terms of reserving in advance and using or the entire community has been ordered to
the space), and meets security needs (e.g., evacuate. Worksheet B14 (in Appendix B)
provides secure space for storing medication, includes a checklist for relocation planning.
records, and drug testing specimens). A final
consideration is whether the alternate facility Another task of the team is to explore, and
is appropriate for the population being served have approved by the program director
(e.g., youth, women with young children). or designee, standby contracts for critical
equipment and quantities of supplies that
Worksheet B12 (in Appendix B) can be would be needed at an alternate location
used to collect data necessary to evaluate (e.g., generators, tents, cleaning supplies
prospective alternate facilities. Worksheet or services). For residential programs,
B13 (in Appendix B) can be used for recording standby contracts may be needed for camp
information about the facilities that are most beds, bedding supplies, and food supplies or
appropriate for internal, local, regional, or services. These contracts become effective only
national disasters. if necessary following a disaster and, typically,
they establish prices at the level in effect on
The program has several options when the day before the incident occurs. Related to
arranging for alternate facilities. It can this, the disaster planning team can research
negotiate with another behavioral health local laws or regulations that protect against
treatment program to provide space for each price increases in periods of disaster.
other as necessary. This approach can be
practical because such programs often have
similar infrastructures. These sorts of mutually Ensure Interoperable
beneficial arrangements are best arranged
in advance and in writing (see Negotiate
Communications
Memoranda of Agreement, in Chapter 3). To continue providing essential services after
Alternatively, the program can arrange a disaster, essential staff members need
to use space at another type of healthcare systems and equipment that allow them to
facility (e.g., nursing home, hospital), or it can communicate with one another, whether
negotiate for space at a non-healthcare-related onsite, at home, or traveling, and to retrieve
facility (e.g., college dormitory, sports complex, and record data in client records and other
motel, community-based facility). files. They also need systems and equipment
that enable them to communicate with key
Essential services may need to be divided partners (e.g., frontline emergency responders;
among more than one alternate site, if no staff at alternate facilities; nonessential staff;
single site meets all requirements. A situation clients in residential settings, at their homes,
may arise in which no alternate location is or at alternate facilities; clients’ families
available or staff members are unavailable and other care providers; insurers and other
to work at or reach the alternate location. payers; vendors; the public).
To prepare for this contingency, the disaster
plan should include a section on temporarily Examples of communications systems include:
transferring clients to another program where
they can be treated as guest clients. Advance • At least one dedicated telephone line and
arrangements are needed, especially if the corded telephone on the premises for use
plan will require that clients be dispersed in case of power failure. Most cordless
among multiple programs (see Prepare for telephones do not work without electricity,
Transfers of Patients, in Chapter 5). and cell phone systems can jam from overuse;
also, individual cell or cordless phones will
The disaster plan needs to account for situations need recharging. (Note: Corded phones
when relocation will occur on short notice, such may run out of power after several hours if
as when the facility has been compromised they are linked by fiber-optic [as opposed to

48
 Chapter 4—Continuity Planning

copper] wires to the telephone company’s • An offsite telephone number that employees
central office.) can call to report status and obtain
information. Programs can partner with
• Cell phones with text messaging
programs in other localities to provide one
capabilities, personal digital assistants, or
another with emergency calling numbers.
Internet-based telephone accounts.
• Battery operated laptops with software
• Two-way radios (e.g., inexpensive walkie-
and memory capacity enabling access to
talkies), satellite phones (rented or
clinical data stored at an offsite server if
purchased), and other devices for person-
the primary facility network is inoperable.
to-person communications when cell and
landline phones are inoperable. Some of • Computers at guest locations that are
these communications devices may not be loaded with software capable of running
secure, so providers must be careful when the program’s necessary files and
relaying client information over them. databases or that have the ability to
access the program’s hosted software site
• An Intranet hot site, which is a private,
containing this information.
password-protected area that can be
accessed only by authorized users and • Emergency contact information in multiple
which can be used to receive status formats (e.g., stored in a computer
information from, and provide information database; entered on paper copies stored
to, employees in a disaster situation. at the office, at home, and in vehicles;
programmed into office phones for speed-

Exhibit 4-5. Communication Tree

The coordinator initiates distribution of a message by contacting the people on the branches directly
below him or her. Those people then contact those below them on the branch. The final people to
receive the message contact the coordinator, completing the chain and confirming that everyone has
been informed. If callers cannot reach an assigned contact, they move to the next person down the
branch, passing along the name or names of those who could not be reached. This information is
passed along until it reaches the coordinator.

Coordinator
home phone, work
phone, cell phone,
email

Staff Staff Staff

home phone, work home phone, work home phone, work
phone, cell phone, email phone, cell phone, email phone, cell phone, email

Staff Staff Staff

home phone, work home phone, work home phone, work
phone, cell phone, email phone, cell phone, email phone, cell phone, email

Staff Staff Staff

home phone, work home phone, work home phone, work
phone, cell phone, email phone, cell phone, email phone, cell phone, email

49
Disaster Planning Handbook for Behavioral Health Treatment Programs

dialing; stored in cell phones). This would • A communication tree, which is an

include the contact information collected in arrangement that distributes responsibility
Worksheet B3 (in Appendix B). among staff to contact all personnel in case
of emergency (Exhibit 4-5).
• Memoranda of Understanding with
amateur radio (ham) operators for Exhibit 4-6 provides information on three
assistance in emergency communications. priority services that can help behavioral
health treatment programs communicate
• An agreement with local TV and radio
in emergencies: Government Emergency
stations to communicate the program’s
Telecommunications Service (GETS),
status to the public in emergencies.
Wireless Priority Service (WPS), and Priority
• Routine reminders to staff members to Listing for Electric Service. The disaster
print or back up to a second location their planning team can research whether its
computer-based personal calendars, address program is eligible for these services.
books, and other critical databases, such as
by synchronizing them to a handheld device The behavioral health treatment program must
that can be password protected. apply to be accepted into the GETS and WPS
systems. The program may be asked to obtain a
• Multiple means of broadcasting alerts to government sponsor and may have to submit a
staff and clients (e.g., intercom for within- letter explaining the nature of the relationship
facility communications; out-of-town phone between the sponsor and the program, the role
number that dispersed staff members can that the program plays in community disaster
call for information about program status; response efforts, and the staff roles that will
group messaging via cell phone, email, or need priority service and why.
Internet; closure listings via TV and radio;
instant messaging via social networks, The disaster planning team can inventory its
such as Twitter). current communications systems to ensure
that redundant, compatible systems have

Exhibit 4-6. Priority Communications in an Emergency

Service Description
Provides priority access to the switches that route telephone calls. This service is most
useful during an event when telephone systems are not damaged but the circuits are
Government overloaded. In this situation, the caller usually hears a very fast or very slow busy signal
Emergency after the number is dialed, indicating that too many people are making calls at the
Telecommunications same time. By using a GETS calling card, subscribers have priority access to the circuit,
Service (GETS) which allows the call to go through. GETS cards are free, but there is a small fee-per­
minute charge when they are used. Further information can be found at http://www.
dhs.gov/government-emergency-telecommunications-service-gets.
Provides priority access to the cellular towers that route cell phone calls. This service
is most useful in situations when the cellular infrastructure is intact but the circuits are
overloaded by a large number of callers. In this situation, the caller usually receives a
Wireless Priority message indicating that the call cannot be completed or receives a fast busy signal. WPS
Service (WPS) subscribers receive priority access through the cellular phone system. WPS is attached
to a specific cell phone number, and the monthly fee is added to the phone bill. Further
information can be found at https://www.dhs.gov/wireless-priority-service-wps.

Ensures first priority for electric service restoration, following service disruption or
shortage, to organizations that provide vital services or that would be most adversely
Priority Listing for
affected by lack of service. In some areas, priority services may not be available to
Electric Service
nonhospital healthcare providers. The disaster planning team should contact the
local power company to learn about eligibility.

50
 Chapter 4—Continuity Planning

been created for person-to-person and data

communications and that the personnel Psychiatric programs that accept Medicare
authorized to use those systems in a disaster and Medicaid are eligible for incentives for
situation have access to authentication adopting certified EHR technology. Programs
procedures and passwords. The team can that do not successfully demonstrate
also seek advice and assistance from its meaningful use of EHR technology by 2015
will have a payment adjustment in their
local disaster planning body and the State
Medicare reimbursement. Information is
disaster behavioral health coordinator on
available from the Centers for Medicare
obtaining the equipment, “gateway” devices and Medicaid Services at https://www.cms.
or patches that enable interoperability, gov/Regulations-and-Guidance/Legislation/
and permissions for communicating with EHRIncentivePrograms/index.html.
emergency responders in disaster. The
team can use Worksheets B15 and B16 (in
Appendix B) to ensure that it has considered To ensure all appropriate records remain
a range of options for ensuring interoperable accessible or are transferred as needed in a
communications. disaster situation, the disaster planning team
can work with management to ensure there is
a current inventory of records and databases
(e.g., temporary and permanent records,
Protect Vital Records those stored in all formats and media). The
and Databases inventory also can include a list of current
software versions necessary to support
Treatment programs may consider housing
functions and files and contact information
their IT equipment offsite at specialized
for the software and hardware companies.
data centers, which offer customers a safe,
secured environment with redundant systems From this comprehensive inventory,
ensuring uninterrupted processes. Programs personnel assigned to this task can identify
also are encouraged to convert from paper the records, databases, and software
medical records to electronic health records necessary to perform essential functions
(EHR; also known as electronic medical and to restore normal operations after a
records, or EMR). These steps can circumvent disaster. Some fields in a database may not
many of the records-related problems that be essential and can be sorted out if needed
can occur in a disaster (Exhibits 4-7 and to save space on paper or on a hard drive.
4-8). For example, EHR stored at a secure Worksheet B17 (in Appendix B) can be
offsite server, such as one hosted by a medical used to ensure that plans are in place for
records software company, can be accessed protecting all vital records and databases.
even if paper records are destroyed at the
original facility, and they can be readily The disaster planning team can check to
accessed by the program if it has relocated confirm whether computer systems staff has
to an alternate site. In addition, EHR can in place a schedule for regularly updating
be transferred, efficiently and securely, to each vital record or database and backing up
another provider as needed. each update on a remote server. The team
also should ensure that copies on paper,
CD-ROM, or encrypted external memory
Information on EHR can be obtained from the
drives can be kept at an alternate location or
Office of the National Coordinator for Health
in a portable, waterproof, and fireproof case
Information Technology, U.S. Department of
Health and Human Services, at that can be carried to an alternate facility as
http://healthit.gov. needed; this case is typically referred to as a
facility go kit (distinct from the personal go
kit addressed in Chapter 3).

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Disaster Planning Handbook for Behavioral Health Treatment Programs

Exhibit 4-7. Benefits of Electronic Health Records (Example 1)

St. John’s Regional Medical Center in Joplin, MO, converted from paper to EHR just weeks before a
tornado devastated the town in May 2011, and this may have “saved lives,” according to Health and
Human Services Secretary Kathleen Sebelius. Patient medical information was relayed within hours to
outlying hospitals treating tornado victims, and St. John’s was able to operate effectively for weeks in
a mobile medical unit. “Think of a typical hospital waiting room, and the infamous clipboard where
somebody is being asked to put together their medical history and prescription regime by memory, and
add a huge traumatic incident on top of that,” Secretary Sebelius said in an Associated Press interview.
“There’s no question that . . . the availability of an electronic record may have actually saved lives.
They were able to immediately go into the treatment phase and not spend a lot of energy trying to
reconstruct (records).”

Source: Zagier (2011).

Exhibit 4-8. Benefits of Electronic Health Records (Example 2)

Access Family Care (AFC) is another Missouri provider that averted a communications breakdown
following the May 2011 tornado. The smaller of its two locations in Joplin, which provided primary
care and behavioral health services, was completely destroyed. The organization had converted to
EHR more than 2 years previously. Clinicians could access records from desktop computers or mobile
devices, and they could reenter the system at the point where they left off without needing a repeat
login. The system had many other useful features, such as e-prescribing and interconnection with a
third-party lab.
The core systems and applications were hosted and maintained by an IT company in an offsite
building. The tornado destroyed that building—except for the data center itself, which was in a
reinforced section that survived. The IT company relocated to temporary quarters and resumed
operations within half a day. “This proved critical for the health center. When they reopened in the
days immediately following the storm, AFC became the focal service delivery point for their own
patients, as well as an emergency access point for others in the community, providing emergency
medical triage and medication refills for community residents in need, while continuing to manage
direct care and assist their own staff and staff families who were affected by the storm. . . . The
experience of Access Family Care in Joplin, as well as of other community health centers at the
epicenter of recent disasters, underscores the importance of investment in HIT [health information
technology] at both the health center and community level. The operating costs incurred by the
center are a manageable share of the overall budget and allow for operational and programmatic
efficiencies while supporting the delivery of care. In the wake of the recent tornado, these dollars are
clearly money well spent.”

Source: Shin and Jacobs (2012, pp. 4–5).

Any electronic forms that are essential for might contain forms required for medications
continuity of operations and emergency ordering, administration, and management,
response (e.g., forms for reporting and as well as client progress note forms and
recording disaster response measures other client forms (e.g., drug testing forms).
such as daily situation reports; records
of expenditures and obligations; client Computer applications and data should be
assessment, intake, treatment planning, and prioritized by management staff responsible
discharge forms) should be available in paper for this function so that those most critical to
copies as backup when the power is down or operations are recovered and brought back
systems are inoperable; these can be kept online first following a disaster. A plan should
in the facility go kit. The facility go kit also be developed for disassembling, transporting,

52
 Chapter 4—Continuity Planning

and reassembling any necessary equipment staff member who should wait for further
in an evacuation. instruction). To ensure effective deployment
of personnel, the disaster planning team
The behavioral health treatment program needs to have in place—and communicate
must ensure that client confidentiality through training and other means—a clear
is maintained as the program shares delineation of the staffing chain of command
information with other sites for client and leaders’ authority in a time of disaster,
transfers and as it creates duplicate if it is different from the chain of authority
records, such as for the facility go kit during regular operations. There also needs
(per requirements of 42 Code of Federal to be a contact list of all staff members,
Regulations [CFR] Part 2, Health Insurance including emergency contact information
Portability and Accountability Act [HIPAA], and after-hours locations. (Personal contact
and Health Information Technology for information, such as home and cell phone
Economic and Clinical Health Act). numbers, should be shared on a need-to­
know basis through the chain of command,
Guidance provided by the Office for Civil and the information should be used only for
Rights, U.S. Department of Health and appropriate purposes.)
Human Services, following Hurricane
Katrina is excerpted in Exhibit 4-9. (Updated Multiple means of communicating among
guidance may be issued in future disasters.) staff need to be in place (see Ensure
If staff members find themselves in a Interoperable Communications, earlier in this
situation in which confidentiality must be chapter). Information on staff credentials and
broken, they should attempt to contact the levels of expertise will be useful, to ensure
State agency that oversees treatment of that no one is moved into an assignment he
behavioral health disorders to explain the or she is not trained or prepared to perform.
situation. If that is impossible, they should
document the circumstances and report the An individual’s willingness to work in a
breach as soon as possible. disaster situation will be affected by concerns
about family, personal safety, and pet care
(Meredith, Eisenman et al., 2011). The
Develop Resources To Manage disaster planning team can recommend
policies that support staff members as they
Human Capital serve during the disaster. These may include
As discussed in the Mitigate Risk section of policies that:
Chapter 3, the disaster planning team can
take steps in advance to limit the extent • Provide staff members with advance
to which staff members are affected by training in disaster self-care.
any disaster that occurs. The team also
• Ensure access to phones or Internet to
can create, in advance of any event, a list
check on family members while working
of providers of social services that will be
through a disaster situation.
available to support staff members with
personal emergency needs (e.g., medical • Allow for adjustments to shift schedules,
assistance, crisis counseling, temporary as needed to perform essential
housing). functions while also managing personal
responsibilities (maintaining 8-hour or
An effective disaster plan provides a shorter work shifts if possible).
mechanism for informing staff members
when the plan has been activated and how • Provide for compensation to employees
each person should respond (i.e., as an who work additional hours in the disaster
essential staff member who should report situation.
immediately for duty or as a nonessential

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Disaster Planning Handbook for Behavioral Health Treatment Programs

Exhibit 4-9. Office for Civil Rights HIPAA Guidance Following Hurricane Katrina
September 2, 2005
U.S. Department of Health and Human Services Office for Civil Rights

Hurricane Katrina Bulletin: HIPAA Privacy and Disclosures in Emergency Situations

Persons who are displaced and in need of health care as a result of a severe disaster—such as Hurricane
Katrina—need ready access to health care and the means of contacting family and caregivers. We
provide this bulletin to emphasize how the HIPAA Privacy Rule allows patient information to be shared
to assist in disaster relief efforts and to assist patients in receiving the care they need.
Providers and health plans covered by the HIPAA Privacy Rule can share patient information in the
following ways:
Treatment. Healthcare providers can share patient information as necessary to provide treatment.
Treatment includes:
• Sharing information with other providers (including hospitals and clinics).
• Referring patients for treatment (including linking patients with available providers in areas where the
patients have relocated).
• Coordinating patient care with others (such as emergency relief workers or others who can help in
finding patients appropriate health services).
Providers can also share patient information to the extent necessary to seek payment for these
healthcare services.
Notification. Healthcare providers can share patient information as necessary to identify, locate, and notify
family members, guardians, or anyone else responsible for the individual’s care of the individual’s location,
general condition, or death. The healthcare provider should get at least oral permission from individuals,
when possible; but, if the individual is incapacitated or not available, providers may share information for
these purposes if, in their professional judgment, doing so is in the patient’s best interest.
Thus, when necessary, the hospital may notify the police, the press, or the public at large to the extent
necessary to help locate, identify, or otherwise notify family members and others as to the location and
general condition of their loved ones.
In addition, when a healthcare provider is sharing information with disaster relief organizations that,
like the American Red Cross, are authorized by law or by their charters to assist in disaster relief efforts,
it is unnecessary to obtain a patient’s permission to share the information if taking the time to get
permission would interfere with the organization’s ability to respond to the emergency.
Imminent danger. Providers can share patient information with anyone as necessary to prevent or
lessen a serious or imminent threat to the health and safety of a person or the public—consistent with
applicable law and the provider’s standards of ethical conduct.
Facility directory. Healthcare facilities maintaining a directory of patients can tell people who call or ask
about individuals whether the individual is at the facility, their location in the facility, and general condition.
Of course, the HIPAA Privacy Rule does not apply to disclosures if they are not made by entities covered
by the Privacy Rule. Thus, for instance, the HIPAA Privacy Rule does not restrict the American Red Cross
from sharing patient information.

Excerpted from Office for Civil Rights (2005).

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 Chapter 4—Continuity Planning

The team, working with human resource willing to report for and stay on duty during
personnel, should review personnel policies to an actual event (Exhibit 4-10). Worksheet
ensure they support continuity of operations B18 (in Appendix B) can be used as a tool for
in a disaster. A central issue is educating considering personnel policies pertaining to a
and preparing staff members so that they are disaster.

Exhibit 4-10. Building Staff Willingness To Respond in Disaster

One OTP reported that during a hurricane, staff members abandoned their posts over concerns that
they would be unable to get home to protect themselves and their families. To avoid a recurrence of
that situation, the program developed a detailed disaster plan that, among other things, clearly advised
staff members of their roles in a disaster and enunciated policies for compensating staff if the program
closed because of a disaster. As a result of these measures, the OTP was better staffed in subsequent
hurricanes.

Source: Podus et al. (no date).

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Chapter 5—Management of Prescription

Medications

This chapter covers disaster planning to support

In This Chapter clients who take prescribed medications for the
treatment of behavioral health disorders or for other
• Give Careful Oversight
medical conditions. The chapter also covers issues
to Clients on Prescription
regarding management of onsite controlled substances
Medications
during a disaster.
• Help Clients Access
Prescription Medications
• Provide for Continued Give Careful Oversight to Clients on
Methadone Dosing Prescription Medications
• Prepare for Transfers of Clients on prescription medications will need to be
Patients monitored to determine if the unusual circumstances
have interrupted or altered their medication regimen.
• Treat the Guest Patient on Depending on the patient and situation, the effects
Methadone Maintenance of medication changes can include withdrawal and
Treatment symptom return. Innumerable kinds of adverse drug
• Handle an Influx of Patients reactions also can occur. The majority of them are
With Opioid Dependence related to drug interactions, occurring when the amount
or action of a drug in the body is changed—usually
• Address the Needs of increased or decreased—by the presence of another drug
Displaced Patients on or multiple drugs. For example, adverse reactions can
Buprenorphine occur from the unanticipated interactions of prescribed
• Refer or Treat Pain Patients, medications, methadone, illicit drugs, over-the-counter
as Appropriate products, and other substances. In cases of patients on
elaborate drug regimens—such as multidrug therapies
• Manage Supplies of for HIV/AIDS, hepatitis C, or severe mental illness—
Controlled Substances consultation with specialists will be necessary to manage
any transitions resulting from the disaster situation.
Worksheet (see Appendix B)
Programs can facilitate care in disaster conditions
• B19 Checklist for for their own patients on prescribed medications by
Management of Prescribed proactively converting from paper medical records to
Medications electronic health records. Electronic recordkeeping
avoids problems caused by destruction of paper records
in disaster and facilitates the transfer of those records to
an alternate facility or guest provider (see Protect Vital
Records and Databases, in Chapter 4).

Help Clients Access Prescription

Medications
Clients may be on prescribed medications for treatment
of mental disorders (e.g., antipsychotic medications,

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Disaster Planning Handbook for Behavioral Health Treatment Programs

benzodiazepines, selective serotonin reuptake more easily obtain medication refills, as needed,
inhibitors, barbiturates). Clients also may from a new medication-dispensing facility:
be on one or more prescribed medications
for treatment of substance use disorders • A photo ID
(e.g., buprenorphine, naltrexone, disulfiram,
• Medication containers of currently
acamprosate). In addition, clients may take
prescribed medications (even if empty)
prescribed medications for medical conditions
(e.g., hepatitis C, HIV/AIDS, diabetes, high • Written prescriptions
blood pressure, pain).
• Packaging labels that contain dose,
In a disaster, clients may need to have their physician, and refill information
prescriptions refilled due to losing access to • Any payment receipts that contain
or running out of their medications. Clients medication information
who are unable to take their regular doses
can experience one or more of the following The program’s executive director or other
symptoms, depending on their diagnoses designated representative can talk to the
and medications: sudden return of psychotic local and State public health departments to
symptoms (e.g., hallucinations, delusions), find out whether psychotropic or substance
recurrence of other psychiatric symptoms (e.g., abuse treatment medications are included in
depression, anxiety), withdrawal symptoms, the public stockpile and to obtain clarification
relapse to substance use, or deterioration of on the disaster conditions under which such
physical condition. Some of these effects can medications would be made available to the
be directly or indirectly life threatening. In program’s clients.
addition, people who become emotionally or
mentally unstable or experience a relapse to A 2006 review of the response to Hurricanes
substance use because of lack of access to their Katrina and Rita found that locations
medications may be at risk for unnecessary or receiving evacuees were not prepared to
lengthy hospitalization or institutionalization, support the prescription replacement/refill
especially if the cause and the treatment of needs of arriving individuals. The report
their condition are unknown by providers of noted, “For some people with psychiatric
emergency care. disabilities, this remains one of their chief
concerns for the next hurricane season”
To lessen the likelihood of clients experiencing (National Council on Disability, 2006,
medication-related problems, the disaster Section III, B2). Therefore, the topic of
planning team can recommend that the medication maintenance for clients should
program adopt policies to educate clients be addressed with local disaster planning
on how to handle emergency situations. For committees, especially with the operators
example, clients can be assisted in reviewing of shelters and evacuation receiving sites.
their options for obtaining prescription Continued client access to prescription
replacements and refills under various medications can be a topic included in
scenarios, such as if the clinic or their tabletop or functional exercises that test the
primary pharmacy is not open or if they are disaster plans of the program, community,
relocated without advance notice because of an and State (see Chapter 7).
unforeseen event. Clients also can be educated
to include a 7-day supply of medication in their
household preparedness supplies (American Provide for Continued Methadone
Red Cross, 2009). Clients can be advised to Dosing
carry all of their medications with them if they
are relocated, even temporarily, and to bring Methadone is a Schedule II substance
with them the following items so that they can under the Controlled Substances Act, which
means that prescribing, dispensing, and

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 Chapter 5—Management of Prescription Medications

transporting methadone is tightly regulated take-home privileges. The disaster planning

by the Drug Enforcement Administration team should check with its State agency that
(DEA), under 42 Code of Federal Regulations oversees behavioral health services to learn
(CFR) 8.12. Many patients on methadone the procedures for accessing patient records
maintenance treatment (MMT) for opioid in emergencies. Issues to cover include:
dependence receive their daily dose at their
opioid treatment program (OTP). For such • The process for accessing the OTP’s own
patients, a disaster that cuts them off from patient information when records at the
the OTP and their daily dose of methadone program are destroyed or inaccessible.
can precipitate withdrawal symptoms and
• The process by which a receiving OTP will be
increase risk of relapse.
able to access the records of guest patients.
To ensure continued dosing in all • Whether an OTP can rely on guest patients
circumstances, an OTP will need access to for dosage information when the home
patients’ dosing information or will need to OTPs are not able or available to verify the
be able to provide that information to another information.
program that will provide guest dosing. This
will be difficult if computer-based records • Whether the OTP will have to obtain
are inaccessible or lost in a disaster. As a patient releases for that information.
mitigation step, the OTP should store and Some States have developed statewide
regularly update patient medical records healthcare communications systems through
(including dose levels and take-home which dosing information can be securely
privileges) at a secure location (e.g., an offsite transferred. Details on one such system, the
server located in a reinforced building). The Washington System for Tracking Resources,
program also should be ready to quickly and Alerts, and Communication, are included in
securely transfer patient records and the Appendix E. An example of the challenges in
supporting software to an alternate location patient dosing after a disaster is illustrated
(see Protect Vital Records and Databases, in in Exhibit 5-1.
Chapter 4).

Some OTPs provide patients with smart Information on the State of Washington’s
ID cards. Each card contains the patient’s statewide healthcare communications
photograph and encrypted medical system, through which dosing
information. A program that uses such information can be securely transferred,
cards should ensure that other OTPs to is available at http://www.doh.wa.gov/
PublicHealthandHealthcareProviders/
which patients may be transferred have the
EmergencyPreparedness/WATrac.aspx.
equipment (and the electric or battery power)
to read the cards. The program also should
provide a backup method for transferring
medical records and verifying patient status In some emergency situations (e.g., an
and identity, because patients affected by impending snowstorm or hurricane that is
disaster may lose all possessions, including expected to make street travel difficult for
their ID cards. Many patients on MMT who a few days), the optimal choice may be to
were affected by Hurricanes Katrina and provide patients with extra take-home doses.
Rita experienced this loss (Maxwell, Podus, & OTPs can prepare in advance to submit
Walsh, 2009). emergency programwide exception requests
to the Substance Abuse and Mental Health
Some State Opioid Treatment Authorities Services Administration (SAMHSA) and to
(SOTAs) maintain a central database with the SOTA, where applicable, to extend take-
identifying information on patients on MMT, home privileges, or to dispense extra take-
including dosage levels, admission dates, and home doses for a reasonable period of time.

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Disaster Planning Handbook for Behavioral Health Treatment Programs

Exhibit 5-1. Distant Dispersal of OTP Patients

An OTP administrator reported that his clinic prepared for disaster situations by backing up its data
to an offsite location. This database could be directly accessed by other clinics owned by the same
company. In addition, the administrator retained hard copies of patient names and dosing histories. This
preparation proved insufficient, however, to deal with the impact of a major hurricane. In its aftermath,
the administrator had to spend hours on the phone with staff members at alternate facilities throughout
the United States and not owned by the same company, verifying data and dosing information for
patients who had been relocated. “Planning is great and having channels and [cooperative agreements]
with other programs is great,” he said, “but you have to understand that people are going to end up
almost anywhere.” The administrator was particularly frustrated by the reluctance of some alternate
facilities to accept his verification. Instead, they requested a signed faxed document authorizing the
patient transfer. Power outages made complying with this request extremely difficult.

Source: Podus et al. (no date).

Exception requests may be submitted to must prepare for transfer and tracking of
SAMHSA online, by fax, or by mail. According patients receiving methadone to an alternate
to SAMHSA, OTPs that submit requests online location or to another clinic that will be able
will typically have a decision, also viewable to provide guest dosing. Steps to accomplish
online, within 1 hour of the submission. these transfers should be included in the
program’s continuity plan.
Information on making requests for exceptions Exhibit 5-2 provides an example of an OTP’s
to the Federal opioid treatment standards continuity plan that was executed before
is available at http://www.dpt.samhsa.gov/
landfall of Hurricane Hugo.
regulations/exrequests.aspx.

Treat the Guest Patient on

A SOTA directory is available at http://dpt2.
samhsa.gov/regulations/smalist.aspx.
Methadone Maintenance Treatment
Every OTP should have procedures for how
to handle people who arrive with or without
advance arrangement and who request
Prepare for Transfers of Patients courtesy methadone dosing after a disaster.
In an impending disaster, a behavioral health The disaster planning team needs to consider
treatment program may have little time in how many such patients its facility can
which to activate its plan for continuity of handle. A small program that does not have
operations (see Chapter 4). This factor is the resources to treat guest patients should
particularly crucial for a residential program consider developing plans and procedures for
that provides medical detoxification or for an referring prospective guests elsewhere. This
OTP, both of which must rapidly accomplish can be formally accomplished through an
several extra steps in its continuity plan. MOA with a larger provider (see Negotiate
Memoranda of Agreement, in Chapter 3).
A program that provides onsite medical
detoxification must prepare for evacuation, Programs that have the capacity to treat
which will involve the transfer and tracking guest patients should follow guidance
of patients and their medical information provided by SAMHSA to State Methadone
to an alternate location—or to another Authorities (SMAs) in States directly affected
program with which it has a Memorandum by Hurricane Katrina and included in the
of Agreement (MOA). Similarly, an OTP

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 Chapter 5—Management of Prescription Medications

Exhibit 5-2. An OTP’s Continuity Plan Executed Before Hurricane Hugo

In 1989, Hurricane Hugo hit South Carolina. The Opioid Treatment Center of Charleston was located
in a flood zone and near a major river. The staff thought the building would flood and that the streets
leading to the program would be impassable for days. Staff members had 5 hours to notify 400-plus
patients that the program might be unable to operate for a few days, to contact State and Federal
officials to obtain permission to dispense extra take-home doses, to dispense the medication, and to
get home themselves to secure their homes or relocate.
The program had agreements with OTPs in other parts of the State, in neighboring States, and with
hospitals and mental health centers (for patients with co-occurring disorders). The six counselors, two
nurses, an administrative assistant, and a program director did the following:
1. Contacted the medical director to report back to the facility to sign take-home orders and to sign
emergency take-home requests to be sent to State and Federal authorities.
2. Called each patient to inform him or her of the situation, using agreed-on emergency contacts where
necessary, and to tell the patient to come to the clinic to pick up the extra doses.
3. Communicated with OTPs in neighboring counties that might serve patients should the program be
unable to reopen within 3 days.
4. Contacted a local mental health service provider to determine whether all patients served by them
had enough prescriptions to ride out the storm and aftereffects.
5. Informed nearby emergency departments (EDs) of the OTP’s closing, in case patients went to an ED
for methadone because they did not receive extra take-home doses.
6. Called the local public communications systems to ask that they broadcast the program’s closure.
All these procedures had been established with scripts that each staff member had access to and used
during the disaster.
There was only one incident: a pregnant mother could not get in to pick up her extra doses. She was
assisted by local ED staff members, who communicated with the medical director for guidance and
assistance. Agreements remain in place with medical and mental health centers, OTPs, and other
community support agencies.

Source: Shirley Beckett Mikell, Clinical Supervisor, The Opioid Treatment Center of Charleston, SC, personal communication,
January 11, 2010.

Federal Guidelines for Opioid Treatment Address the Needs of Displaced

(SAMHSA, 2013). See Exhibit 5-3. Patients on Buprenorphine
There are hundreds of thousands of patients
Handle an Influx of Patients With receiving buprenorphine products for the
maintenance or detoxification treatment of
Opioid Dependence opioid dependence. Most of these patients are
A disaster may disrupt distribution of street being treated by office-based, Drug Addiction
drugs, causing individuals dependent on illicit Treatment Act-waived physicians, in settings
opioids and not in treatment to turn to an OTP other than OTPs. Buprenorphine patients
for help. A disaster also can be a life-changing displaced by disasters may be treated in OTP
experience that impels people to enter settings.
treatment. OTPs should anticipate a potential
rush of new patients. Guidance provided by
the Division of Pharmacologic Therapies (DPT) Additional buprenorphine treatment resources
may be found at the Buprenorphine Physician
on handling displaced patients who are opioid
& Treatment Program Locator at http://
dependent and not currently in treatment is buprenorphine.samhsa.gov/bwns_locator.
presented in Exhibit 5-4.

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Disaster Planning Handbook for Behavioral Health Treatment Programs

Exhibit 5-3. Guidance for Treating OTP Patients From Areas Affected by Emergency Closure of

Programs in the Event of a Disaster

Programs receiving displaced patients should make every effort to contact the home treatment
program of people who have had to evacuate the area in which they live after an emergency or
disaster. Information about the program may be obtained from the OTP Directory on the DPT Web
site (http://dpt.samhsa.gov) or at the SAMHSA Behavioral Health Treatment Services Locator at http://
findtreatment.samhsa.gov. In an emergency, program personnel may disclose information to the
program medical director; program physician or mid-level practitioner, as appropriate; registered nurse;
or dosing nurse without a patient’s signed consent. If unable to contact the patient’s home program,
the OTP receiving a displaced patient should follow the procedures listed below along with existing
emergency plans:
• The emergency guest patient should show a valid form of picture identification that includes an
address in close proximity to the area affected.
• The patient should show some type of proof that indicates the patient was receiving services from
a clinic located in one of the affected areas. Examples of proof may include a medication bottle,
program identification card, or a receipt for payment of fees, etc. In cases in which the patient does
not have any items of proof, including picture identification, the physician or mid-level practitioner,
as appropriate, should use his or her best medical judgment combined with a stat drug test for the
presence of methadone (lab test with quick turnaround, dipstick, or similar procedure).
• OTP staff may administer the amount of medication that the patient reports as his or her current
dose; however, each patient is reminded that the dose that is reported will be verified with the home
program as soon as possible. It may be prudent to closely observe an unknown patient for several
hours post-administration to ensure that the dosage decision was correct, or take appropriate medical
action in the event the dose was too high. In cases in which the reported dose appears questionable,
it is best to use good medical judgment when determining the dose level. In certain cases in which
the patient can demonstrate no prior enrollment in treatment or medication dosage amount, it may
be advisable to treat the patient as a new admission and follow initial dosing procedures for a routine
admission. (See 42 CFR § 8.12 (h) (3) (ii).)
• Emergency guest patients should be medicated daily with take-home doses provided only for
days that the program is closed (Sundays and holidays). The clinic should have a plan to administer
methadone appropriately and safely on days or at times when the program is closed. If the patient’s
current take-home status is verified, take-home doses may be provided in accordance with State and
Federal regulations (42 CFR Part 8). In the case of a patient who is unable to receive daily treatment
at the program location due to medical hardship, travel restrictions, or other hardship, take-home
medication for unsupervised use may be considered using the SMA-168 “Request-for-Exception”
process.
• Documentation of services provided to displaced patients should be a priority for OTPs. The OTP
should assign a clinic identification number and maintain a temporary medical record for each guest
patient. Reasonable efforts should be made to contact the patient’s home program periodically
to verify patient information prior to dispensing medication. The results should be recorded in the
temporary chart. OTP staff should record the day, date, amount of medication administered to each
patient along with any observations made by the staff. As time passes and affected OTPs reopen,
some patients may elect to remain in treatment at the receiving facility and change from guest to
permanent status. At the conclusion of emergency treatment, the receiving program may be asked to
report to the SMA and/or SAMHSA the number of patients treated and the types of services provided.

Excerpted and adapted from SAMHSA (2013, pp. 60–61).

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 Chapter 5—Management of Prescription Medications

Refer or Treat Pain Patients, Manage Supplies of Controlled

as Appropriate Substances
During a disaster, some people on opioid OTPs should take steps to ensure an
medication for pain may lose access to adequate supply of approved opioid
medication and experience withdrawal. Some treatment medications, such as methadone
may seek help from an OTP. SAMHSA (2013) and buprenorphine, are on hand for
recommends that such people be referred emergency dosing and other purposes (see
to a local physician, preferably a pain Chapter 6 on pandemic flu preparations).
management specialist. See Exhibit 5-5. Some emergencies may necessitate that a
behavioral health treatment program remove
controlled substances such as methadone

Exhibit 5-4. Guidance on Working With Patients Who Are Dependent on Opioids and Not
Currently in Treatment
Individuals dependent on opioids—including heroin or prescription drugs—may arrive at the guest
treatment program seeking help as a result of the disruption in the supply of street drugs. OTPs
may admit, treat, and dose these patients under existing guidelines and regulations. Initiation on
buprenorphine products may be appropriate for patients new to medication-assisted treatment.

Excerpted from SAMHSA (2013, p. 61).

Exhibit 5-5. Guidance on Working With Displaced Patients Treated by Pain Clinics
Patients who are being treated for pain with methadone by a physician may contact an OTP when they
run out of medication and have no access to the former treatment setting. The first response should
be to refer the patient to a local physician, particularly a pain management specialist. Additionally, the
SAMHSA guidelines provide the following guidance:
• Patients, in general, are not admitted to OTPs to receive opioids only for pain, but there are
exceptions to this principle. The Narcotic Addiction Treatment Act and the Drug Addiction Treatment
Act (DATA) were established to allow for maintenance and detoxification treatment, using certain
opioid controlled substances like methadone and buprenorphine. These requirements and limitations
in no way affect the ability of a practitioner to utilize opioids for the treatment of pain when acting
in the usual course of medical practice. Consequently, when it is necessary to discontinue a patient’s
opioid therapy for the treatment of pain by tapering or weaning doses, there are no restrictions, under
Federal opioid treatment regulations, with respect to the drugs that may be used. Because this is not
considered “detoxification” as it is applied to addiction treatment, no separate DEA registration as an
OTP or DATA waiver requirements apply.
• Patients with a chronic pain disorder and physical dependence are managed by multidisciplinary
teams that include pain and addiction medicine specialists. The site of such treatment may be in a
medical clinic or in an OTP, depending on each patient’s need and the best utilization of available
resources. Similarly, addiction patients maintained on methadone or buprenorphine are not
prohibited from receiving needed pain treatment including, when appropriate, adequate doses of
opioid analgesics.
• Patients who are diagnosed with physical dependence and a pain disorder are not prohibited from
receiving methadone or buprenorphine therapy in an OTP for either maintenance or withdrawal, if
such a setting provides expertise or is the only source of treatment.

Excerpted from SAMHSA (2013, pp. 61–62).

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Disaster Planning Handbook for Behavioral Health Treatment Programs

from the premises during evacuation or concern or for police escort when transporting
relocation. The program needs to know, in program supplies to a new location. Again,
advance, legal procedures for moving the the program can facilitate these requests
controlled substances and the procedures by establishing relationships with the law
for requesting moves. DEA or the SOTA enforcement agency before any disaster
can provide the most current advice on this and ensuring that the appropriate law
matter. enforcement contact information is available
in the disaster plan.
Emergency authorization for requests to move A program’s supply of controlled substances
controlled substances in response to a disaster may become inaccessible (e.g., if the
may be submitted to DEA via http://www.
methadone safe is buried in rubble or under
deadiversion.usdoj.gov/disaster_relief.htm.
water). A representative of the program
should consult with the local DEA agent,
the SOTA, and the program’s medication
To facilitate the request process, the disaster suppliers to develop contingency plans for
planning team can educate the DEA agent resupply. The local health department may
for its jurisdiction, in advance, about the be able to facilitate resupplies from local
controlled substances that it stocks and about strategic stockpiles, hospital supplies, or
the potential need for expedited permissions other sources. The treatment program can
in emergencies. The relationship between the coordinate, in advance, with these other
behavioral health treatment program and parties to create signed agreements that
the DEA agent can be fostered through joint detail procedures and protocols for emergency
participation in the community’s disaster transfers of controlled substances. At a
preparedness planning and related practices minimum, these agreements should be
or drills. reviewed and updated annually.

Programs should inform the local law Worksheet B19 (in Appendix B) is a
enforcement agency, in advance of any checklist of planning issues to support
emergency, that controlled substances are patients who take prescribed medications
on the property. The disaster planning team and to manage controlled substances in a
may request that the facility be considered disaster.
for high-priority protection if looting is a

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Chapter 6—Planning Issues for Pandemic

Influenza

A regional or global disease outbreak, known as a

In This Chapter pandemic, presents a unique kind of hazard. Unlike
tornadoes, earthquakes, and other events typically
• Potential Effects of Pandemic associated with the word disaster, the primary effects
Influenza of a pandemic would not be destruction of property and
• Procedures To Reduce traumatic injury, but rather sickness and death.
Influenza Transmission
Influenza is the infectious disease most likely to
• Vaccines become a pandemic. Influenza can spread throughout
• Antiviral Medications the world in a matter of weeks and before sufficient
quantities of antiviral medications and vaccines can
• Hygiene Policies be produced and distributed. The Occupational Safety
and Health Administration (2009) estimates that
• Staffing Policies
workplace absences could reach 40 percent during
• Staff Attitudes peak weeks of a community outbreak.
• Planning Assumptions for An influenza pandemic will likely recur in waves that
Pandemic Influenza may last for months. A community that has been
• Drafting and Activating the affected by a pandemic may only partially recover
Pandemic Plan before experiencing another wave of illness. Because a
pandemic affects an entire region simultaneously, the
response and recovery help that might otherwise be
Medical Offices and Clinics available could be very limited.
Pandemic Influenza Planning
Checklist, from the U.S. A pandemic presents such a unique disaster scenario
Department of Health and that behavioral health treatment programs are
Human Services (HHS) and the advised to develop a specific plan for pandemic
Centers for Disease Control and response. The disaster planning team can develop
Prevention (CDC) can be used this plan, or it can delegate the task to a pandemic
in conjunction with this chapter. planning committee. The pandemic plan can be
It is available at http://www. attached to the basic plan as a Pandemic Appendix.
flu.gov/planning-preparedness/ This chapter presents the information that should be
hospital/medofficesclinics.pdf. considered as this appendix is prepared.

Potential Effects of Pandemic Influenza

When influenza reaches pandemic proportions, the
operations of a behavioral health treatment program
can be adversely affected in multiple ways. Significant
numbers of staff members, clients, and residential
patients may become ill or die. Staff shortages may occur
because workers have been quarantined, want to avoid
exposure, or must care for ill family members. There may
be increased mental stress on staff and clients.

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Disaster Planning Handbook for Behavioral Health Treatment Programs

Specific client populations may be at special Procedures To Reduce Influenza

risk of illness or complications. Typically, this Transmission
includes women who are pregnant (Exhibit
6-1) and people from racial and ethnic CDC continuously updates its advice regarding
minority groups (Exhibit 6-2). Other groups procedures to reduce influenza transmission.
that may be at special risk include people These include annual vaccination for employees
who are 65 years or older; have asthma or (and vaccination against specific strains of
other chronic pulmonary, cardiovascular, pandemic influenza as they are made available)
hepatic, hematological, neurologic, and minimizing potential exposure by
neuromuscular, or metabolic disorders such promoting good respiratory hygiene and cough
as diabetes; are immunosuppressed; or are etiquette, separating symptomatic clients from
residents of a nursing home or other chronic- other persons, and a range of other actions.
care facility. Children younger than 5 and
children and youth on long-term aspirin
therapy also are at special risk (HHS, Seasonal influenza guidance for the general
public and health professionals from CDC is
2009a).* Exhibit 6-3 lists potential effects of
available at http://www.cdc.gov/flu and from
an influenza pandemic on the specific types of HHS at http://flu.gov.
treatment programs.

Exhibit 6-1. Pregnant Women at Special Risk From Influenza

Pregnant women who contract influenza are at increased risk for severe illness or death, and babies born
to them have increased risk of adverse outcomes (Rasmussen, Jamieson, & Breese, 2008). The disaster
planning team should consider actions the program can take to mitigate risk for pregnant clients during
a pandemic outbreak, such as the following:
• Provide services to pregnant women in ways that minimize their exposure to others (e.g., in individual
rather than group settings, in separate areas of the facility).
• Educate women to protect themselves against infection while performing their roles as family
caregivers and members of the workforce.
• Help women develop a plan to maintain prenatal care while minimizing exposure.
• Provide counseling to women on the benefits and risks—for themselves and for their fetuses—of
influenza vaccine, antiviral medication, antifever medication, and antibiotics, such as for secondary
bacterial pneumonia.
• Support pregnant women in their compliance with physician recommendations for use of antiviral and
other prescribed medications.

Exhibit 6-2. Racial and Ethnic Minorities Disproportionately Affected by Influenza

Historically, people from racial and ethnic minority groups have been disproportionately affected by severe
influenza due to higher rates of underlying health conditions as well as cultural, educational, and linguistic
barriers that interfere with adoption of intervention strategies (Hutchins, Fiscella, Levine, Ompad, &
McDonald, 2009). To minimize disparities, programs can involve members of racial and ethnic minorities in
its pandemic preparedness and response planning and facilitate their participation in community pandemic
planning. Programs also can advocate for equitable allocation of resources including antiviral medications
and vaccines. When providing pandemic planning education and services, programs can offer culturally and
linguistically sensitive educational materials and interpreters for non-English-speaking clients.

*
An influenza virus may affect people atypically. For example, in the 1918 pandemic, healthy young adults comprised
the predominant risk group. It is theorized that the virus triggered an overload of response from the immune system
and that people with stronger immune systems were more susceptible to an overreaction to the virus.

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 Chapter 6—Planning Issues for Pandemic Influenza

Exhibit 6-3. Potential Effects of Influenza Pandemic on Behavioral Health Treatment Programs
Program Type Potential Pandemic Effects
Client drop-in and attendance at individual appointments and group events may
decline. Alternatively, client drop-in and attendance may surge because of concern,
panic, or lack of other psychological or medical support.
Clients may not heed instructions to stay home if experiencing influenza-like symptoms,
and consequently transmit the illness to other clients and staff.
Mental health emergencies may increase as the result of a disruption in client support
Outpatient
and access to ongoing treatment.
Treatment
Programs Services may have to be provided using procedures to reduce influenza transmission
(addressed in the section below).
Staffing shortages may occur as clinicians become ill or stay at home to care for ill family
members.
The entire program or specific services may close during local outbreaks of disease.
Revenues may decline dramatically, with effects on the viability of the program.

Patients may become ill and need to be isolated.

Residential Staff may need to take care of patients who become ill.
Treatment The facility may be quarantined.
Programs Visitation may need to be suspended or highly restricted. Electronic communications
may replace actual onsite visitation.
Beds may be redirected for use by patients with influenza.
Medical and nursing staff may be redirected to care for patients with influenza.
Necessary antiviral drugs may be slow in arriving or not be available at the necessary
Medically levels.
Managed
Detoxification Influenza symptoms (e.g., fever, nausea, diarrhea) may be difficult to differentiate from
Programs withdrawal symptoms.
A surge in patients may occur that includes people who are infected with influenza,
people who misinterpret influenza symptoms as withdrawal symptoms, and people who
seek psychological or medical support.
An OTP may need to provide patients with take-home methadone doses for longer
periods than usual (following guidelines from the Substance Abuse and Mental Health
Services Administration, Center for Substance Abuse Treatment [CSAT], Division of
Pharmacologic Therapies [DPT]).
The program may need to provide patients with take-home doses earlier in their
recovery than usual (again, following CSAT’s guidelines).
Opioid
Treatment Increased numbers of patients may need to have doses brought to them because they
Programs (OTPs) have contracted a communicable disease.
Hospital emergency departments may be operating at capacity and unavailable for
methadone maintenance treatment of patients whose home OTP has closed.
Patients in fear of not receiving scheduled doses may overwhelm the program as they
seek additional take-home supplies or support.
Programs may be at increased risk of theft or diversion of medications.

Prevention The program may be discontinued until the local pandemic crisis is over.
Programs

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Disaster Planning Handbook for Behavioral Health Treatment Programs

Some modified procedures require advance A decision on whether to provide residential

planning and investment. For example, patients with the pandemic vaccine,
increased staff telecommuting may require if available, should be made by senior
improvements to the program’s communications management in consultation with the local
infrastructure and the development of policies. health department. If vaccines are offered,
Telephone or Web-based counseling may the program will need to implement policies
require setup of equipment and testing that and consent forms to support this practice.
ideally are conducted in advance of a pandemic. If possible, a patient’s pertinent medical
Prior approval from funding sources, such information (e.g., previous vaccinations and
as insurance providers and Medicaid, for responses, allergies, risks, contraindications)
substitute forms of counseling may be needed should be reviewed before vaccinating. The
to facilitate reimbursements. Any plans to program may prefer to refer nonresidential
provide counseling through remote means clients and staff to their primary care
(e.g., telephone or Internet) need to specify how providers or local clinics for vaccinations.
clients who do not have telephones or computers
will access the service. In addition, the program
should review any program modifications (e.g., Antiviral Medications
telephone or Internet counseling) for their
potential impact on patient confidentiality. The use of prescription antiviral medications
Programs can seek guidance on planning for is an important strategy for suppressing the
modifications to procedures during an influenza spread of pandemic influenza (Homeland
pandemic from the State disaster behavioral Security Council, 2005). Recommendations
health coordinator. The program is also advised for antiviral drug use in an influenza
to work with its attorney to ensure that pandemic and plans for distribution of
procedures comply with privacy requirements public stockpiles of antiviral medications
and to develop documents for new procedures continuously evolve. Priority distribution
(e.g., client release forms for phone, texting, or of antivirals will be to workers at critical
Internet counseling. infrastructure organizations—those providing
goods or services essential to community
Procedures should be tested and practiced to health, safety, or well-being.
identify weaknesses in the plan and to prepare
staff. Chapter 7 provides information on The program’s executive director or appointed
testing the plan and training staff to use it. representative is advised to talk to contacts
at the public health department to clarify
whether antivirals from the public stockpile
will be made available to the program or
Vaccines
whether the program should purchase its own
The disaster planning team can ensure that supply. The team also should become informed
the program has policies in place to facilitate of the medical, legal, and ethical issues
vaccination of staff and clients for seasonal involved in the use and rationing of antivirals.
flu, if medically indicated. The program’s
executive director or other appointed Purchase of an antiviral stockpile should
representative can contact local and State be considered by all programs, especially if
public health departments to learn about the program has a residential component,
the community’s policies on distribution for serves clients who have compromised
a particular pandemic influenza vaccine, immune systems, or serves women and
when it becomes available, and to ask for the girls (as indicated in Exhibit 6-1, pregnancy
inclusion of the program’s essential staff, as has been found to increase risk for severe
healthcare professionals, on the priority list. illness or death from some influenza strains).
Antiviral stockpiling could be costly, but
financial assistance may be available from

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 Chapter 6—Planning Issues for Pandemic Influenza

manufacturers. All plans to stockpile should • Provide preventive education for staff
be coordinated with local and State emergency and clients (e.g., on the importance of
pandemic preparedness efforts and in maintaining overall good health, avoiding
conjunction with other measures to protect unnecessary exposure to people who are ill,
workers and maintain continuity of operations. and keeping all suggested immunizations
up to date to protect against illness that
A behavioral health treatment program with weakens the ability to fend off influenza).
medical staff may become an authorized point of
distribution (POD) for antiviral medications and • Educate staff and clientele on influenza
vaccines. The local or State health department symptoms, social distancing procedures
coordinating these efforts can provide guidance (the public health practice of encouraging
on the requirements for becoming a POD. If the people to keep their physical distance from
program does not choose to become a POD, it each other to avoid infection), and other
should establish plans to transport residential influenza-related topics.
patients to a location where vaccinations • Make alterations to sick leave policies
are offered or to contract with the health during pandemics to encourage those who
department for personnel to come onsite to are infected or recently exposed to the
provide vaccinations. virus to remain away from the facility for
the duration of their contagious period.
• Make temporary modifications during
Hygiene Policies pandemic conditions to the program’s
In consultation with program management, appointment policy to ensure that clients
the disaster planning team can review and who are contagious are not penalized for
revise hygiene policies, including policies to: canceling appointments at short notice.
Exhibit 6-4 describes how a residential
• Encourage hand hygiene among staff and
facility educated residents about flu
clients.
prevention hygiene and pandemic scenarios.
• Reduce spread of virus through respiratory
means (e.g., coughing etiquette).
• Stock sanitation supplies (e.g., Staffing Policies
disinfectants, hand sanitizers, facial The order of succession in the disaster plan
tissues, face masks). may need to be extended several people deep
to ensure that leadership and other essential

Exhibit 6-4. Pandemic Education Provided to Staff and Residential Patients

In our facility, monthly meetings are held for staff and residents that cover a range of topics focused
on the importance of staying well. Some of these topics include correct hand washing techniques;
proper use and disposal of tissues; and the importance of keeping warm, drinking enough fluids, and
dressing appropriately. We also talk about how we would manage an outbreak, including containment
of [residential] houses, and staff management of infectious diseases (e.g., staff stress, communications,
shifts). Staff and residents need to know whom they can contact for further information.
“Talking about it” includes more than just specific education sessions. In our cases, it means building
and maintaining an environment in which individuals feel they are able to tell someone if they are not
feeling well and in which monitoring signs of illness is viewed as a positive response rather than an
intrusion. Effective communication will also enable us to identify the early signs of stress and anxiety
among our residents for early intervention.

Excerpted from Hughes (2010, pp. 39–40).

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Disaster Planning Handbook for Behavioral Health Treatment Programs

positions are filled. In addition, multiple threat is significant. Workers who felt they
layers of staff trained in sanitation duties (e.g., could be effective and that the threat was
disinfecting surfaces, changing linens, removal high had a declared rate of willingness to
of trash) may need to be identified because respond that was 31.7 times higher than the
sanitation will be essential during a pandemic. rate for workers who perceived that both
their ability to respond and the disaster
The program’s pandemic plan can provide threat were low (Barnett et al., 2009).
direction for rapid identification of staff
members who become symptomatic and for The implication for behavioral health
staff substitutions so those identified workers treatment program disaster planners is that
can be sent home. If staff levels become staff competencies and attitudes need to be
critically low, the program may need to hire assessed to ensure that all employees are
qualified staff members from a staffing agency, prepared, and feel prepared, for the duties
or it may need to refer or transfer clients. they will be expected to perform under
However, if there is concern about contagion, pandemic conditions. Workers who are not
other programs may not be willing to treat confident of their abilities may need more
guest clients even if a mutual aid agreement training in their designated disaster roles
had been negotiated. Local hospitals also and education about how their contributions
may be overwhelmed with ill patients and make a difference. Barnett et al. (2009) also
find it difficult to dispense methadone to suggest that in an actual pandemic situation,
referred OTP patients or to treat patients program management should not minimize
needing medical detoxification. The disaster the threat. In addition, staff members should
planning team is advised to consider these be encouraged to develop pandemic-specific
scenarios. The executive director or appointed emergency plans for their own households.
representative should clarify assumptions
with the behavioral health treatment
programs with which the program has mutual Planning Assumptions for Pandemic
aid agreements, with staffing agencies, and
with hospital representatives.
Influenza
When drafting the Pandemic Appendix, the
The disaster planning team should identify first step is to identify planning assumptions
alternative ways to serve clients if the for pandemic influenza. These assumptions,
program reduces its operations or closes, and if based on available data and information
other programs are not immediately available from public health authorities, form the basis
to serve its clients. For example, an OTP may for planning decisions. Exhibit 6-5 provides
provide patients who qualify with take-home examples of planning assumptions.
doses for an extended duration, following
CSAT’s DPT guidance for pandemic situations.
Drafting and Activating the
Pandemic Plan
Staff Attitudes
The Pandemic Appendix should state who
A survey of 1,835 public health workers determines when the plan is activated
indicates that the most important factor because of pandemic conditions, what
influencing workers’ willingness to respond information will be used to make the
for duty during a pandemic is their confidence decision to activate the plan, and the
that they can perform the emergency modified policies and procedures that will
duties expected of them and that their be implemented. The appendix also should
response makes a difference. A second factor describe actions that will be taken if essential
influencing workers’ willingness to respond services cannot be provided because of staff
is their perception of whether the pandemic shortages, quarantine, facility closures, or

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 Chapter 6—Planning Issues for Pandemic Influenza

Exhibit 6-5. Examples of Pandemic Influenza Planning Assumptions

Issue Assumptions
The time interval between an alert issued for pandemic influenza and its arrival in the
community may be short or long (ranging from days to months).
Time Factors The pandemic may last as long as 18 months and occur in several waves, with mortality and
morbidity increasing and decreasing sporadically.
Waves of severe disease may last 1–4 months.
A vaccine may not be available for many months after an influenza pandemic begins, and
supplies of it may be limited.
Antivirals may not treat or protect against the pandemic influenza virus strain.

Prevention Even if effective, antiviral medications may be in limited supply, and their distribution may
and occur in phases.
Treatment of Infection control strategies and social distancing strategies (e.g., postponing public
the Influenza gatherings such as support group meetings, substituting Internet and phone counseling for
in-person sessions) can be used to slow the spread of disease.
Isolation of ill people will be required.
Quarantine of healthy people exposed to ill people may be implemented.

Clients with weakened immune systems or who are pregnant are at higher risk for severe
illness and death.
Twenty to fifty percent absenteeism for staff, clients, vendors, and services within the
community may occur. Absenteeism will be the result of staff members and clients becoming
ill, staying home to care for children or family members, or refusing to go to the facility for
fear of contracting the virus.
Every person who becomes ill is likely to miss from a few days to many weeks of work.
In a severe pandemic, 0.1 percent–2.5 percent of people who become ill may die.
Clients
Staff members and clients (including residential patients) may develop symptoms while on
and Staff
program premises.
Members
Staff members may be asked to perform tasks that are not part of their normal job
descriptions, to provide coverage for essential services; alternatively, they may be transferred
to other duties or facilities where coverage is needed, or they may be assigned to work
extended or additional shifts.
In a severe pandemic, essential staff members may be drafted into the care of the sick, and
residential facilities may be commandeered to create pandemic wards separate from the
main hospitals.
In a severe pandemic, fear and anxiety levels will increase.

Services will be stressed but will remain functional.

Telecommuting practices may be implemented for support services (e.g., administrative
functions).
Services Critical functions carried out by contractors, consultants, and vendors may be erratic.
The program may be unable to rely on mutual aid resources to support its response efforts.
Staff may accrue an unbudgeted amount of overtime or use higher-than-normal amounts of
leave and sick time.
Excerpted and adapted from San Francisco Department of Public Health (2006, p. 6).

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Disaster Planning Handbook for Behavioral Health Treatment Programs

other pandemic-related events, and it should assistance. This notification plan will
describe the conditions under which the plan likely not differ significantly from those
will be deactivated and staff will return to for other types of emergencies. Model text
normal duties. for notification messages can be composed
in advance and included in the Pandemic
The local public health department is a Appendix. Examples of message objectives
primary source of information about local include:
pandemic conditions, and CDC provides
continuously updated information on • Informing staff and clients of pandemic
conditions nationwide. conditions.

The decision to activate the pandemic plan • Counteracting rumors and misinformation.
must be made carefully. The hardships • Providing basic situational anxiety
imposed by reducing or modifying services management information and suggested
to clients must be weighed against the techniques (e.g., deep breathing, relaxation
risks of infection. If pandemic procedures techniques, keeping hydrated).
are activated too soon, the hardships will
outweigh the benefits and adherence (such as • Providing staff members with a resource
to social distancing procedures) may wane. for their confidential use (e.g., an employee
However, if procedures are activated too assistance program) that can help them
late, the infection prevention benefits may be with pandemic-related challenges.
limited. • Providing information on the general
health conditions of colleagues and clients
The program’s Pandemic Appendix should (including notifications of death).
detail how staff members, clients, and
the public will be notified of changes in • Providing referral to bereavement
service provision and procedures including counseling and other social supports.
closings and alternative options for seeking

72
Chapter 7—Completing, Testing,
Activating, and Deactivating the Plan
As explained in Chapter 1, the behavioral health
In This Chapter treatment program’s disaster planning team drafts
the sections of the written disaster plan as it gathers
• Assemble the Plan information based on a risk assessment document; the
• Distribute the Plan team recommends to management implementation
options (following the processes outlined in Chapters
• Train and Test 2 through 6). This chapter explains the steps involved
in completing and working with the plan. These steps
• Activate the Plan in Disaster
include assembling and distributing the plan, training
• Deactivate and Revise the staff on using it, testing the plan, activating the plan
Plan when a disaster incident occurs, deactivating the plan
when the state of emergency ends, revising the plan
• Coordinate With the based on lessons learned from the disaster response,
Community in Recovery and providing support to staff and clients after the
• Support Staff Members, disaster.
Clients, and Community
After the Disaster
• Continuously Revise and
Assemble the Plan
Update the Disaster Plan When all sections of the disaster plan are completed,
they can be assembled into one document. Worksheet
Worksheets (see Appendix B) B1 (in Appendix B) provides a checklist of all items
that should be included in the plan. The following
• B1 Checklist for the Written elements are inserted at the front, or Preface, of the
Disaster Plan document:
• B20 Disaster Plan Training
and Testing Log • Cover page . Include the title, date, and facility
covered by the plan.
• Signature page . This page includes signatures of
the program’s executive director and other senior
managers (e.g., the chair of the program’s board of
directors) that affirm that the program’s leadership
approves and endorses the plan. Management can
sign off on sections as they are completed or at one
time on the entire document.
• Title page . This page includes placeholders to
record the date of changes and revisions to show
that the plan is being kept current and to indicate
that the document is the current version.
• Record of changes . This record indicates changes
that were made to the plan and the dates they were
made.

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Disaster Planning Handbook for Behavioral Health Treatment Programs

• Record of distribution . This page one organization or unaffiliated programs that

indicates who has received a copy and are geographically close. Behavioral health
where other copies are stored (e.g., in the treatment programs may consider providing
facility go kit). staff with compensated time for training
conducted outside regular working hours and
• Table of contents . A list of the sections
other incentives to enhance disaster readiness
in the plan (as well as a tabbed page at
skills. Disaster-related courses are offered
the start of each section) helps users find
by the Emergency Management Institute of
information quickly.
the Federal Emergency Management Agency
(FEMA) and by local chapters of the American
Red Cross. Worksheet B20 (in Appendix B)
Distribute the Plan
can be used to log training and testing activities.
Once management approves the plan, the
disaster planning team should distribute it to Each training exercise should build on the
all relevant parties. Staff members assigned previous one (FEMA, 2009). Types of exercises
responsibilities under the plan can receive the are summarized in the following sections.
full document or the sections relevant to their
duties, and they can be given two copies—one
Discussion-Based Seminars
for the office and one for home. The disaster
planning team can develop a management- Training can begin as the disaster plan is
approved summary to provide to other being developed. With the support of senior
staff members. The team also can provide management, the disaster planning team can
copies of the summary or the full plan, as schedule briefings to familiarize staff with
appropriate, to the State agency that oversees basic disaster concepts and staff roles and
behavioral health disorder treatment and to to build support for the disaster readiness
other organizations with which the program concept.
has developed relationships for disaster
response (e.g., the local departments of health
and social services, the local jurisdictional Discussion-Based Workshops
emergency managers, the local chapter of the Through facilitated discussions, staff can
American Red Cross). provide input on the disaster plan and the
policies that would support the plan, draft
specific sections of the written plan, and develop
Train and Test supporting products, such as job-related aids.
In an actual disaster, no one has time to read
a disaster plan. Training and testing staff Tabletop Exercise
members familiarize them with procedures so
A tabletop exercise provides initial training
that they can respond efficiently when and if
to key staff members who are responsible for
a disaster does occur, using the written plan
executing the disaster plan. In a classroom
as a reference.
setting, a scenario is presented by a facilitator,
and participants talk through possible
Disaster exercises can help staff members
responses (FEMA, 2009). New developments
build the skills and teamwork they will
in the scenario are presented during the
need when executing a disaster plan. These
exercise so that participants reconsider
activities also identify problems or gaps in
previous decisions and plan their next actions.
the plan that should be addressed, as well as
Participants share ideas and discuss options
actions that can mitigate risk. These drills
for responding to the hypothetical situation,
and exercises may involve staff from, and take
without the pressures that occur in a real
place within, a single facility. Alternatively,
or simulated event. The tabletop exercise
they may encompass the multiple facilities of
familiarizes participants with their roles and

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 Chapter 7—Completing, Testing, Activating, and Deactivating the Plan

responsibilities and reveals issues that require The simulation evolves over time; for example,
revision or additional planning. Tabletop the scenario might start as a wildfire that is
exercises also enable local organizations to followed by a rainstorm and landslide.
network and share ideas on improving disaster
readiness. Exhibit 7-1 summarizes a tabletop As its name implies, the functional exercise
exercise involving opioid treatment programs typically tests a function rather than the
(OTPs) in King County, WA. Exhibit 7-2 entire breadth of activities that would be
provides an example of the useful networking engaged in a real disaster. For example, an
that can occur at a tabletop exercise. exercise might focus on one of the following:

• Coordination of staff members from two

Functional Exercise behavioral health treatment programs for the
In a functional exercise, participants act out transfer of clients from one facility to another
responses according to their assigned roles • Communicating during a severe pandemic
in a simulated disaster scenario rather than with clients who have limited English
simply discuss potential responses. This role- proficiency
play places participants under time pressure.

Exhibit 7-1. Tabletop Exercise for Opioid Treatment Programs (1.5 hours)
Element Description
City of Seattle Office of Emergency Management
Drug Enforcement Administration (DEA)
Evergreen Treatment Services
King County Healthcare Coalition
Participating Public Health—Seattle and King County
Organizations Therapeutic Health Services
University of California, Los Angeles
Veterans Administration (Washington State Department of Veterans Affairs)
Washington State Board of Pharmacy
Washington State Division of Alcohol and Substance Abuse
Determine ability to support timely decisions about operations of OTPs in an emergency
Exercise Demonstrate ability to coordinate communication and resources among key stakeholders
Objectives Evaluate process for activating mutual aid agreements among OTPs
Discuss protocols and rules of regulatory agencies
Friday, May 29, 7:59 a.m.: A very large earthquake occurred, rumbling through the entire
Puget Sound region for 2 minutes. Damage is visible in the entire county. All landline and
cell phones are jammed. Electricity is out in the neighborhoods of SODO, Capitol Hill, and
First Hill.
Friday, May 29, 8:45 a.m.: Media report a shallow 6.8 magnitude earthquake occurred in the
Scenario Black Diamond area and extensive damage in Kent, Auburn, and Renton. The 520 bridge
Timeline and has collapsed. The Alaskan Way viaduct is closed.
Major Events Saturday, May 30: Landline and cell phones work sporadically. Text messages are getting
through. Limited power returns to SODO region. Evergreen Treatment Services has power
but no water.
Monday, June 1: President signs a disaster declaration for the area.
Monday, July 6: Several moderate aftershocks (2–5 in magnitude) have occurred since May 29.
Continued on next page

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Disaster Planning Handbook for Behavioral Health Treatment Programs

Exhibit 7-1. Tabletop Exercise for Opioid Treatment Programs (continued)

Element Description
OTPs that have generators will assess what equipment, including alarms and medication
storage areas, are powered by their agencies’ backup generator.
OTPs will advise staff members that they should plan alternate routes to work.
OTPs will work on strategies for communicating with staff members, patients, and the
general public, including the media, in a disaster. This includes developing communication
strategies for contacting patients if power is down and landline and cell phones are
jammed and encouraging staff members to have an out-of-area phone contact.
OTPs will work on developing strategies for communicating with one another about their
ongoing activities in a disaster.
OTPs that anticipate a need for enhanced services in a disaster (e.g., heightened security,
priority in restoring power, transportation considerations) should immediately contact their
local Emergency Operations Center for guidance on addressing problems identified during
the exercise. The contact at the Emergency Operations Center should be at least at the
level of captain.
Local OTPs may need to coordinate with OTPs outside King County. Although nothing is
Lessons currently in place to enable that process, the use of the existing mutual aid agreement as a
Learned template for working with OTPs in other counties is encouraged.
A State-level entity would be most appropriate to take the lead in facilitating emergency
preparedness activities among OTPs across the State.
To balance the needs of patient access to medication, patients’ and staff members’ physical
safety, security of medication, and provider’s liability exposure, OTPs will need support from
regulatory authorities.
DEA wants OTPs to keep it apprised of their activities in a disaster but does not want to
impede program activities. DEA will provide OTPs with an emergency contact telephone
number.
The King County jail needs a disaster plan for dosing methadone patients if a licensed OTP
is unable to do so.
Verification is needed as to whether general population shelter operators will allow patients to
bring take-home doses of methadone into the shelter, even when prescriptions can be verified.
A medically based disaster plan is needed to address citizens who are chronically
intoxicated and/or who abuse opioids and are suddenly cut off from their substance of
choice because of the disaster.

Excerpted and adapted from King County Healthcare Coalition (2009).

Exhibit 7-2. Beneficial Networking at a Tabletop Exercise

Various community agencies and organizations participating in a tabletop exercise can exchange useful
information that might otherwise not be shared. During the tabletop exercise described in Exhibit
7-1, discussion turned to the use of generators for emergency power. The manager of an emergency
responder agency indicated that OTPs might be able to obtain priority fuel assistance for their
generators during an outage. This advice was useful to the OTP administrators, because lines at gas
stations can be long during an emergency. One administrator who had experienced a communitywide
extended power outage after a storm reported that he had had to divert staff members from their
treatment functions to the task of finding gas: “I’d load them up with gas cans and send them out to fill
them all up, so we’d have fuel for a couple of days.”

Source: Podus et al. (no date).

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 Chapter 7—Completing, Testing, Activating, and Deactivating the Plan

• Notifying families and referral agencies in their areas. Leaders of behavioral health
during an emergency evacuation at an treatment programs should actively network
adolescent residential treatment program with local emergency managers so that the
leaders are aware of joint exercises, can testify
• Executing a plan for sheltering-in-place
to the importance of being included in the
that provides for the unique needs of
planning and execution of these exercises, and
populations defined as at-risk (U.S.
are invited to be involved.
Department of Health and Human
Services [HHS], 2012)
Evaluation is an integral part of any training
Typically, it will be more feasible, cost-
exercise, whether a tabletop or a full functional
effective, and productive for a behavioral exercise. Decisions on exercise goals and how
health treatment program to participate in to evaluate these goals should be decided
a community-sponsored functional exercise upon at the beginning of the process. Effective
than to conduct one on its own. The disaster exercise planning begins with setting these
planning team that has an established measurable goals. The exercise itself ends
working relationship with local emergency with a measurement of success in achieving
planners, as described in Chapter 2, can those goals, which leads to decisions that may
stay apprised of when such exercises are include how to improve the current disaster
scheduled and find out how to arrange for plan, policies, and trainings. The resulting
program staff members to participate. document is referred to as an After-Action Plan
and includes improvement goals, objectives,
responsible parties, and timelines for making
Field Exercise these improvements. FEMA’s Homeland
Security Exercise and Evaluation Program
A field exercise is a full-scale enactment of is a tool for developing training exercises
a disaster, with people acting out their roles and establishing and evaluating the exercise
in real time, using actual equipment, and goals. This tool can be scaled up or down
testing multiple emergency functions. A field for exercises of all sizes and types, and it can
exercise takes a great deal of planning, is modified based on the needs of the program.
disruptive to normal business operations, It is located at https://www.llis.dhs.gov/hseep.
and is expensive. Thus, a behavioral health
treatment program is unlikely to conduct
this kind of exercise on its own. However,
its staff can benefit from participating in a Activate the Plan in Disaster
field exercise organized by local or regional
When a disaster occurs, swift mobilization
emergency management leaders.
can lessen the impact. Through the process
of testing and training, staff can become
Although community field exercises can
familiar with the four key steps to take in
be beneficial, behavioral health treatment
disaster response. These are:
programs do not have a strong record of
participating in such efforts. A survey of 90
1. Activate the program’s Incident Command
OTPs found that, whereas all responding OTPs
System (a key person is designated Incident
had disaster plans and participated in tabletop
Commander to manage response; see
and functional exercises of their plans, less
Designate Personnel To Assume Command
than 17 percent had partnered with another
for Incident Response, Chapter 3).
agency for a field exercise (Podus, 2009). Less
than 30 percent reported that they knew “a 2. Decide on objectives and priorities to
good deal” about how local government and minimize risk to persons and property,
community agencies (e.g., mental health based on the nature of the incident (e.g.,
services providers, law enforcement, emergency if a wildfire is approaching a program, the
management, the American Red Cross) would first priority will be immediate evacuation
handle circumstances related to a disaster of the facility and a second priority will
77
Disaster Planning Handbook for Behavioral Health Treatment Programs

be protection of property). The disaster members to make decisions on when and how
plan’s hazard-specific appendices provide to contact their supervisors and on the actions
guidance on objectives for response to a to take. Recurrent disaster training for all staff
specific threat, such as a wildfire. members and clarity about succession planning
are the best protections against a sudden
3. Create an Incident Action Plan to accomplish disaster that occurs when senior management
the objectives in a specified timeframe. staff members are not present. Training for
The plan will indicate assignments and the management and staff can be offered in short
resources that can be used to complete those sessions over time and build from basic to more
assignments. An informal draft can suffice advanced skills, based on roles. This kind of
unless the incident response is expected to be graduated training schedule avoids disruption
large and complex. of treatment services.

4. Follow through on the plan, except where

it is necessary to make modifications to the Deactivate and Revise the Plan
plan to address changing circumstances.
Deactivation is the process by which an
Familiarity with disaster procedures helps organization ends its state of emergency and
leaders activate a disaster response at the right resumes normal operations. Examples of
time—not too soon, too late, or unnecessarily. deactivation activities for a behavioral health
Exhibit 7-3 illustrates timing ramifications. treatment program include:
Two key variables affect the decisionmaking
process: (1) whether the program has received • Returning from an alternate facility to the
advance notice of the disaster, and (2) when home location after the disaster incident
the incident occurs (during or after business has passed, such as when a mandatory
hours). A hurricane or severe blizzard evacuation has ended. (Among disaster
usually allow for advance notice, whereas response planners, this return is called
an earthquake or hazardous materials spill reconstitution [FEMA, 2004].)
typically will not. Disaster incidents that
• Contacting outpatient clients to inform
occur when key staff members are off duty or
them that counseling services have
are out of town may require subordinate staff

Exhibit 7-3. Effect of Timing Decisions on Staff

Nurses are key personnel in OTPs. In an impending disaster such as a blizzard or hurricane, they are
often among the last to leave the premises because they are the ones who provide patients with
emergency take-home medications.
In a disaster, the treatment program must request, and receive approval for, any needed dispensing
exceptions from the Center for Substance Abuse Treatment’s Division of Pharmacologic Therapies.
Carrying out a decision to provide emergency doses can take up to 72 hours after approval has been
obtained, according to providers who have been through weather-related emergencies. That much time
may be necessary for notifying patients, for patients to reach the clinic during business hours, and for
the providers to dispense the medication.
“Sometimes I wish they would just let us know a little bit sooner,” reported a nurse who has worked
during several weather-related emergencies. She recalled one situation in which she stayed to dispense
medication so long that “on our drive home, the wind force was really bad. . . . I could feel my car
going like this [gestures]. I’m really having to hold my car in the road. I would like to see them maybe
make a decision a little bit sooner. . . . I mean, you know, [it] would be a little bit more safe for us, too,
as the employees.”

Source: Podus et al. (no date).

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 Chapter 7—Completing, Testing, Activating, and Deactivating the Plan

resumed a regular schedule and to an After-Action Plan is prepared. The plan is

reschedule appointments, as needed. often presented in table format and identifies
goals and objectives, due dates for completion
• Encouraging clients to reengage in services
of tasks, and the responsible parties for
by having their assigned counselors
completing each objective. Depending on
contact them by phone about additional
the kind of incident that has occurred, the
services or referrals, as needed.
recovery phase guided by an After-Action Plan
• Arranging for the return of patients on can last weeks, months, or longer.
methadone maintenance who have received
guest dosing at another facility (and the Adequate planning and training for
retrieval of records related to this treatment). disaster can expedite the recovery time.
Staff should be encouraged to follow the
• Completing reconstruction of all or part of disaster plan’s recovery procedures (e.g.,
a facility that had been destroyed. for contacting insurance representatives,
After deactivation, designated disaster collecting necessary documentation, filing
planning team members should debrief staff claims, applying for recovery grants and
to obtain a complete picture of the program’s aid, recording recovery expenses). A system
response throughout the incident. Based on this should also be in place to allow staff members
information, the team may be able to identify to record their extended hours of duty during
steps it can take to improve future preparedness and after the disaster so that they can be
and response. With the approval of senior duly compensated and recognized. Exhibit 7-4
management, the team can update or revise the provides examples of recovery steps.
plan and retest it to ensure that the corrective
actions are workable and appropriate.
Coordinate With the Community
When a disaster occurs or when a training in Recovery
exercise is completed, the disaster response
leadership prepares an After-Action Report. The behavioral health treatment program’s
This report summarizes the event, lists the involvement with its community’s recovery
strengths and weaknesses of the response, and may be governed by the extent to which it
presents lessons learned. Based on this report, engaged in predisaster recovery planning

Exhibit 7-4. Examples of Recovery Steps

• Keep staff members and clients away from debris, floodwaters, and damaged property; do not allow
reentry to the building until permitted by the program’s security officer or other officials.
• Prioritize and address needed repairs to damaged buildings and grounds, and take necessary steps to
prevent new hazardous incidents (e.g., address erosion caused by a storm so that basement flooding
does not occur).
• Inform staff of procedures for documenting recovery steps and expenses to facilitate reimbursements.
• Arrange for inspections by certified safety specialists as required by circumstances.
• Clean, disinfect, or discard wet items to avoid mold.
• Ventilate and clean shelter areas.
• Restock emergency supplies.
• Reimburse and thank providers of aid and emergency supplies.
• Evaluate the disaster response and recovery, and use this evaluation to update the disaster plan.
• Provide avenues to inform staff of any updates to the disaster plan.

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Disaster Planning Handbook for Behavioral Health Treatment Programs

and other recovery preparedness, mitigation, person involved. Professionals who claimed
and community resilience-building work (see disability benefits also will need permission
Chapter 2). Community recovery is managed to return to duty from their physicians or
by local governments, in conjunction with therapists.
nongovernmental partners and stakeholders
and with State and Federal agencies.
Behavioral health treatment programs The Disaster Distress Helpline is the Nation’s
first hotline dedicated to providing disaster
are most likely to become involved via the
crisis counseling. The Helpline operates
Health and Social Services Recovery Support 24 hours a day, 7 days a week. This free,
Function, as defined by the National Disaster confidential, and multilingual crisis support
Recovery Framework (U.S. Department of service is available via telephone (1-800-985­
Homeland Security, 2011a).* 5990) and SMS (text TalkWithUs to 66746) to
U.S. residents in psychological distress due
to natural or human-caused disasters. Callers
Appendix B of the National Disaster Recovery are connected to trained crisis counseling
Framework includes predisaster and professionals. The Helpline staff provides
postdisaster checklists and planning activities confidential counseling, referrals, and other
by sector, including private and nonprofit needed support services. Information on the
sectors. They can be accessed at: http://www. Helpline is available at http://disasterdistress.
fema.gov/pdf/recoveryframework/ndrf.pdf. samhsa.gov.

Clients can benefit from extra support (e.g.,

Support Staff Members, Clients, educational sessions, pertinent handouts,
and Community After the Disaster additional counseling sessions, access to
a crisis hotline) to help them maintain
The emotional well-being of staff is an recovery following a major calamity. The
important consideration throughout the program can provide clients with a list of
disaster recovery phase. Stress management recovery resources that has been updated
mechanisms (e.g., regular rather than after the disaster to reflect changes in
overtime shifts as much as possible, organizations, locations, meeting dates,
compensatory time for personal recovery and times. The program also may take on
needs) can be built into the recovery action other activities to support the mental and
plan to reduce the psychological burdens substance use disorder recovery communities
for staff. Staff members should always be (e.g., arranging for translation services at
referred outside the program for assessment meetings of mutual-help groups, organizing
or treatment of personal stress reactions transportation to those meetings, providing
related to the disaster (this does not refer to space for a meeting at the facility, ensuring
incident briefings or debriefings that are part that mutual-help groups are available
of the program’s efforts to share information for specific populations such as those
during disaster response and recovery). with co-occurring disorders or those with
One option for providing staff support is to pharmacological dependency).
contract with a local employee assistance
program for these services. Traumatized Finally, through its participation in the
mental health professionals should be able community’s coordinated disaster recovery,
to resume their normal duties when they are the behavioral health treatment program
no longer symptomatic, but such decisions should stay alert to the needs of the local
need to be made on an individual basis by the community after the disaster. The program
administrator, the clinical supervisor, and the may be able to offer targeted assistance;

This Recovery Support Function is coordinated by the Office of the Assistant Secretary for Preparedness and
*

Response, HHS.

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 Chapter 7—Completing, Testing, Activating, and Deactivating the Plan

for example, it may be able to partner with the program’s services or facilities—the plan
other agencies to offer SBIRT services— must be reviewed, evaluated, and updated.
screening, brief intervention, and referral This cycle is continuous and ever challenging,
to treatment of mental, substance use, or requiring resources and commitments
co-occurring disorders (Substance Abuse from leadership and the whole staff. Yet
and Mental Health Services Administration, the benefits of disaster preparedness and
2011b). SBIRT assessments can be offered planning for behavioral health programs,
on quarterly or yearly anniversaries of the clients, and staff cannot be underestimated.
disaster or as requested. Programs may The effort that goes into continuous disaster
want to be especially proactive about offering planning can save lives and mitigate the
SBIRT services to community members who long-term impact of disaster on those whom
were directly affected by the disaster or who the program serves.
were involved in response efforts (e.g., police,
firefighters, search-and-rescue volunteers,
shelter staff, members of the media who
reported on the disaster).

Continuously Revise and Update

the Disaster Plan
The development, planning, and testing
cycles of any good disaster plan are ongoing.
After every test and every activation—and
in tandem with any significant change to

81
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Laditka, S. B., Murray, L. M., & Laditka, J. N. (2010). In the eye of the storm: Resilience and
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intervention, and referral to treatment (SBIRT). Retrieved June 20, 2013, from
http://www.samhsa.gov/prevention/SBIRT/index.aspx

Substance Abuse and Mental Health Services Administration. (2013, April). Federal guidelines
for opioid treatment. Retrieved July 9, 2013, from http://www.dpt.samhsa.gov/pdf/FederalG
uidelinesforOpioidTreatment5-6-2013revisiondraft_508.pdf

U.S. Department of Health and Human Services. (2008). Integration of the Medical
Reserve Corps and the Emergency System for Advance Registration of Volunteer Health
Professionals (Version 2). Retrieved June 20, 2013, from http://www.medicalreservecorps.
gov/File/ESAR_VHP/ESAR-VHPMRCIntegrationFactSheet.pdf

U.S. Department of Health and Human Services. (2009a). CDC recommendations for the
amount of time persons with influenza-like illness should be away from others. Retrieved
June 20, 2013, from http://www.cdc.gov/h1n1flu/guidance/exclusion.htm

U.S. Department of Health and Human Services. (2009b). National Health Security Strategy
of the United States of America. Washington, DC: Office of the Assistant Secretary for
Preparedness and Response.

U.S. Department of Health and Human Services. (2010). Coping with the Gulf oil spill -
Mental health information. Retrieved June 20, 2013, from http://www.hhs.gov/gulfoilspill/
mentalhealth.html

U.S. Department of Health and Human Services. (2011a). HHS disaster behavioral health
concept of operations. Washington, DC: Office of the Assistant Secretary for Preparedness
and Response, Office of Policy and Planning, Division for At-Risk Individuals,
Behavioral Health, and Community Resilience.

U.S. Department of Health and Human Services. (2011b). Public health preparedness
capabilities: National standards for state and local planning. Atlanta, GA: Division of
State and Local Readiness, Office of Public Health Preparedness and Response, Centers for
Disease Control and Prevention.

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U.S. Department of Health and Human Services. (2012). At-risk individuals. Retrieved June
20, 2013, from http://www.phe.gov/Preparedness/planning/abc/Pages/at-risk.aspx

U.S. Department of Homeland Security. (2008). National Incident Management System. FEMA
Publication P-501. Washington, DC: Author.

U.S. Department of Homeland Security. (2011a). National disaster recovery framework:

Strengthening disaster recovery for the nation. Washington, DC: Author.

U.S. Department of Homeland Security. (2011b). National Preparedness System, November

2011. Washington, DC: Author.

U.S. Department of Homeland Security. (2011c). National preparedness goal (1st ed.).
Washington, DC: Author.

U.S. Department of Homeland Security. (2013). National response framework (2nd ed.).
Washington, DC: Author.

Washington State Department of Health and Public Health—Seattle & King County. (2012).
Frequently asked questions—2012. Retrieved June 20, 2013, from http://www.doh.wa.gov/
Portals/1/Documents/1400/WATracFAQ.pdf

White House. (2011, March 30). Presidential Policy Directive/PPD-8: National preparedness.
Retrieved June 20, 2013, from http://www.dhs.gov/xlibrary/assets/presidential-policy­
directive-8-national-preparedness.pdf

Zagier, A. S. (2011, August 2). Sebelius touts electronic health records in Joplin. New
Tribune. Retrieved June 20, 2013, from http://www.newstribune.com/news/2011/aug/02/
sebelius-touts-electronic-health-records-joplin

Zwiebach, L., Rhodes, J., & Roemer, L. (2010). Resource loss, resource gain, and mental health
among survivors of Hurricane Katrina. Journal of Traumatic Stress, 23(6), 751–758.

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Appendix B—Worksheets

Worksheet B1 Checklist for the Written Disaster Plan

Worksheet B2 Checklist for Disaster Planning

Worksheet B3 Checklist of State and Community Representatives and Groups

Worksheet B4 Checklist of Disaster Planning Discussion Topics

Worksheet B5 Sheltering-in-Place Checklist

Worksheet B6 Record of Memoranda of Agreement and Qualified Service Organization

Agreements

Worksheet B7 Incident Command System Positions

Worksheet B8 Identify Essential Functions

Worksheet B9 Identify Essential Staff Positions

Worksheet B10 Essential Staff Roster

Worksheet B11 Checklist for Continuity Planning

Worksheet B12 Requirements for Alternate Facilities

Worksheet B13 Alternate Facility Arrangements by Disaster Scenario

Worksheet B14 Checklist for Relocation Planning

Worksheet B15 Checklist for Maintaining Communications With Essential Groups

Worksheet B16 Checklist of Records and Databases To Ensure Interoperable Communications

Worksheet B17 Checklist for Protecting Records and Databases

Worksheet B18 Checklist for Managing Human Capital

Worksheet B19 Checklist for Management of Prescribed Medications

Worksheet B20 Disaster Plan Training and Testing Log

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Worksheet B1 Checklist for the Written Disaster Plan
Name Date
Instructions: Use with Chapter 1, Rationale and Process for Planning, and Chapter 7, Completing, Testing, Activating, and Deactivating the Plan.
List the dates that each component of the disaster plan was drafted and compiled into one resource or updated.

Component Component
Completed Updated Preface
(date) (date)
Cover page (title, date, and facility covered by the plan)
Signature page (with placeholders to record management and, if applicable, board of directors’ approval of the plan
and confirmation of its official status)
Title page (with placeholders to record the dates that reviews/revisions are scheduled/have been made)
Record of changes (indicating when changes have been made and to which components of the plan)
Record of distribution (including internal and external recipients identified by organization and title)
Table of contents
Component Component
Completed Updated Basic Plan
(date) (date)
Statement of purpose and objectives
Summary information
Planning assumptions
Conditions under which the plan will be activated
Expense support of plan and impact on budget
Procedures for activating the plan
Sequence of actions to be taken
Procedures and resources for managing requests
Methods and schedules for updating the plan, communicating changes to staff, and training staff on the plan
Component Component
Completed Updated Functional Annex: The Continuity of Operations (COOP) Plan
(date) (date)
Essential functions and essential staff positions
Continuity of leadership and orders of succession
Leadership for incident response
Alternate facilities (including the address of and directions/mileage to each)
Continued on next page
 Worksheet B1 (page 2)
Component Component
Completed Updated Functional Annex: The COOP Plan (continued)
(date) (date)
Memoranda of Agreement (MOA) and qualified service organization agreements (QSOAs)
Interoperable communications
Vital records and databases (backups and form of information)
Management of human capital
Staff training plan
Testing and revisions of plan
Component Component Other Functional Annexes
Completed Updated
(date) (date) List the annex for each essential activity that requires procedural instructions.

Component Component Hazard-Specific Appendices

Completed Updated List the appendix for each hazard identified by the hazard identification and risk assessment (HIRA)
(date) (date) as most likely to occur and for which specific response guidance is necessary.

Component Component Implementing Instructions

Completed Updated
(date) (date) List the materials necessary to perform essential tasks in emergency.
Safety policies and procedures
Job aids (checklists, worksheets, laminated wallet cards or sheets, scripts that staff can use when providing disaster-
related information to clients and the public)

Appendix B—Worksheets
Communication tree listing (home, work, and cell phone numbers; email addresses)
Contact information for essential groups (see Worksheet B3)
MOA and QSOAs
Building addresses, phone numbers, floor plans, and building evacuation routes
Community maps
Other:
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Worksheet B2 Checklist for Disaster Planning
Name Date
Instructions: Use with Chapter 2, Beginning the Disaster Planning Process. Indicate by date when each planning step has been addressed.

Date Addressed Planning Step

Disaster planning team leader has been selected.

Disaster planning team members provide representation for all departments, including:
• Safety/security
• Clinical management/services
• Medication management/services
• Counseling and case management services
• Public relations (handling communications with client families, the media, the recovery community, and the broader community)
• Staff training and orientation
• Compliance (privacy and regulatory knowledge)
• Operations management
• Engineering maintenance
• Housekeeping services
• Food services
• Pharmacy services
• Transportation services
• Purchasing agent and contracts management
• Medical records
• Computer hardware and software system
• Human resources
• Billing
• Corporate compliance (e.g., human rights, privacy, regulatory compliance)
• Grant writing
• Other members as appropriate (e.g., department heads; resident and family representatives; representatives of relevant
cultures, languages, special interest groups; those with special emergency expertise, such as paramedic training)
The organization’s leadership provides support to the team.
The team has reviewed requirements for disaster planning.
The team has coordinated with others in the State and community (see Worksheets B3 and B4).
A hazard identification and risk assessment (HIRA) has been prepared.
Planning objectives and assumptions have been specified; objectives are measurable and have been approved by leadership.
Other:
 Worksheet B3 Checklist of State and Community Representatives and Groups
Name Date
Instructions: Use with Chapter 2, Beginning the Disaster Planning Process. Indicate by date when networking for disaster response has been
established with each listed representative or group. Provide names, titles, and contact information. If multiple parties are involved in the
networking, attach a sheet listing all of them.

Date State/Community Representative/Group Names, Titles, and Contact Information (phone number[s], email)
Addressed
State disaster behavioral health coordinator
Other behavioral health treatment programs in the community
Public health department
Emergency response organizations
Local office of the Drug Enforcement Administration (DEA)
State Opioid Treatment Authority (SOTA)
Organizations of Pre-Credentialed Volunteers such as Citizen
Corps Council (CCC) or Medical Reserve Corps (MRC)
Voluntary organizations
Vendors and other nearby businesses
Media contact and Public Information Officer of Incident
Command System (ICS)
Other:

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Worksheet B4 Checklist of Disaster Planning Discussion Topics
Name Date
Instructions: Use with Chapter 2, Beginning the Disaster Planning Process. Indicate by date when each action item has been addressed with the
State disaster behavioral health coordinator (Part 1) and with public health department/local emergency planners (Part 2).
Part 1: Action items to address with the State disaster behavioral health coordinator

Date Addressed Action Item

Obtain information on pertinent accreditation, licensing, or reimbursement requirements as well as regulations and laws
governing disaster planning as it relates to behavioral health treatment programs.
Become informed regarding State and local disaster planning contacts and the established network of organizations involved in
disaster planning at the local level.
Obtain access to, and provide input on, the State disaster plan for behavioral health treatment programs.
Learn about procedures for obtaining State, Federal, and private-sector assistance (including financial assistance) for disaster
preparedness, disaster recovery, and expansion of services to respond after a disaster.
Learn about assistance that can be obtained via the State from the U.S. Public Health Service Commissioned Corps, the
Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP), and volunteer groups.
Learn about education, training, and support opportunities, including opportunities for staff members to learn about personal
emergency preparedness.
Develop ways to coordinate disaster planning with that of other behavioral health treatment programs in the State.
Obtain information about alternate sites that can provide behavioral health services in a disaster and the procedures for arranging
reciprocal Memoranda of Agreement (MOA) or qualified service organization agreements (QSOAs) with these entities.
Become informed of opportunities for trained staff to participate in the State and local disaster response drills and tabletops,
within the scope of providing appropriate services (e.g., psychological first aid and crisis intervention).
Discuss the unique opportunities and capabilities of the program to assist its community in a time of disaster, the support it may
need from the State in a disaster, and the special services it can provide after a disaster.
Other:
Continued on next page
 Worksheet B4 (page 2)
Part 2: Action items to address with the public health department/local emergency planners

Date Addressed Action Item

Obtain access to the community’s emergency operations plan.
Learn whether behavioral health treatment programs’ capabilities are included in the community’s emergency operations planning
and, if not, request their inclusion as an annex under Emergency Support Function (ESF) #8.
Educate local emergency leadership about the program’s services, its importance to the community, the assistance the program
and the local recovery community can provide in a disaster, and special needs the program and its clients may have in a disaster.
Coordinate with emergency responders on notification procedures in a disaster incident.
Learn about education and training opportunities for the disaster planning team and/or for program staff (e.g., through Citizen
Corps Councils).
Learn about potential hazards that are particular to the community served by the program (i.e., obtain a hazard identification and
risk assessment [HIRA] from the Local Emergency Planning Committee).
Learn about the Emergency Management Assistance Compact (EMAC) and how this might affect behavioral health treatment
programs.
Consider and plan how all this information will be shared with leadership, the disaster planning team, and other staff members as
appropriate.
Other:

Appendix B—Worksheets
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Disaster Planning Handbook for Behavioral Health Treatment Programs

Worksheet B5 Sheltering-in-Place Checklist
Name Date
Instructions: Use with Chapter 3, Preparing for Disaster. In column 1, indicate when the preparation listed in column 2 has been addressed or
updated.

Date(s) Addressed/ Preparation for Sheltering-in-Place

Updated
Shelter space has been identified that offers maximum protection for the particular hazards deemed most likely, according to
the hazard identification and risk assessment (HIRA). Multiple spaces may be required for facilities located on more than one
floor of a building or occupied by a large number of persons. Sheltering space may be different for different forms of disaster.
Emergency supplies have been stockpiled in the shelter areas within the site, preferably in movable containers, such as
wheeled plastic storage bins. The quantity of supplies is based on the maximum number of people onsite at any one time. A
plan is in place to rotate or discard and restock any perishables or supplies that expire, such as batteries and bottled water. An
accurate inventory of these supplies is kept current.
The shelter space provides for communications (such as having a landline phone), sanitation, the needs of those who are
mobility impaired or have special requirements, and pets, if any are routinely on premises.
The shelter plan is coordinated with other tenants of the building.
A chain of authority is established for communicating the need to shelter-in-place and indicating the all-clear.
Orders to shelter-in-place will be issued through several channels so that everyone onsite is reached, including those who are
visually or hearing impaired or who do not speak English as their primary language. Members of the local disability community
and special language groups have been consulted to determine the most effective strategies for notification.
For each shelter space, one or more staff persons should be assigned presheltering tasks, such as (if time permits):
• Shutting down critical operations including the ventilation system if advised given the emergency.
• Transporting the facility go kit and an emergency supply of medications.
• Locking doors.
• Sealing the room as needed for the specific hazards (e.g., a biohazard incident) that warrant sealed rooms.
• Taking a head count (using a prepared roster) of those sheltering.
• Assisting sheltering persons in contacting family or others to inform about their location.
• Arranging for personal comfort during confinement (e.g., coordinating sleeping arrangements).
• Maintaining contact with emergency authorities.
• Monitoring communications for official instructions.
Multiple means are in place for alerting local authorities when sheltering-in-place so that they can assist if the situation further
deteriorates or there is a medical emergency.
Staff and clients have been apprised of and drilled in sheltering plans to enhance willingness and cooperation when a call to
shelter-in-place is issued. People cannot be forced to shelter-in-place except by government emergency authorities.
 Worksheet B6 Record of Memoranda of Agreement and Qualified Service Organization Agreements
Name Date
Instructions: Use with Chapter 3, Preparing for Disaster. In the left column, list the agreements that have been negotiated. For each agreement,
indicate the organization involved (if a multiparty agreement has been made, attach a sheet listing all parties), where the written agreement is
stored, its expiration date, and special notes (e.g., costs, limitations).

Organization Name, Address, and Location of

Agreement Expiration Date Notes
Contact Information Agreement

Appendix B—Worksheets
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Disaster Planning Handbook for Behavioral Health Treatment Programs

Worksheet B7 Incident Command System Positions
Name Date
Instructions: Use with Chapter 3, Preparing for Disaster. Complete at least the top table. For each position, list the primary staff member and one
or more backups. Worksheet B10 can be used to create a roster for the Incident Command System (ICS) positions.

Position Primary Backup Backup Backup

Incident Commander
Liaison Officer
Safety Officer
Public Information Officer
Agency Executive

Position Primary Backup Backup Backup

Operations Team Leader
Planning/Intelligence Team
Leader
Logistics Team Leader
Finance/Administration
Team Leader
 Worksheet B8 Identify Essential Functions
Name Date
Instructions: Use with Chapter 4, Continuity Planning. Complete a copy of this worksheet for each department. List all functions that the
department performs.

Department:

Is required Is a support
to maintain function
Provides vital Is required by Is essential for other reasons: Essential:
safety for for other
services to regulation or
Function clients and essential
clients: Check law: Check (√) staff: Check functions: If yes, explain below Yes or No
(√) if yes if yes (√) if yes Check (√) if
yes

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Disaster Planning Handbook for Behavioral Health Treatment Programs

Worksheet B9 Identify Essential Staff Positions
Name Date
Instructions: Use with Chapter 4, Continuity Planning. Complete a copy of this worksheet for each department. In the left column, list the
department’s essential functions (those determined to be essential on Worksheet B8) in priority order. In the right column, identify the staff
position(s) necessary to perform the function.

Department:

Essential Function Essential Staff Position (Note: There may be more than one.)
 Worksheet B10 Essential Staff Roster
Name Date
Instructions: Use with Chapter 4, Continuity Planning. Complete a copy of this worksheet for each essential staff position identified in Worksheet
B9. Record contact information for the primary staff member and backups who can perform the essential staff position’s duties.

Essential Staff Position:

Information Primary Staff Member Backup Backup Backup

Name
Office phone
Office email
Alternate email
Cell phone
Home phone
Phone contact outside city*
Notes†
*
Each staff member should provide emergency contact information, using a phone number (e.g., a friend’s or relative’s number) that is in a location distant from the facility (for use in
situations in which local communications systems are not working).
†
Add any information pertaining to the staff member’s availability and scheduling preferences in emergency.

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Disaster Planning Handbook for Behavioral Health Treatment Programs

Worksheet B11 Checklist for Continuity Planning
Name Date
Instructions: Use with Chapter 4, Continuity Planning. Indicate by date when each planning question has been addressed or updated.
All Program Types
Date(s) Addressed/
Updated Planning Question

What is the approximate number of active clients participating onsite in services at various times of day?
Do client medical/service records have current contact information?
Have clients been requested to designate an emergency contact and signed a release of information allowing the release of
specific information in case of an emergency?
How can intake procedures be expedited in a time of disaster? Have procedures been written to support these actions? Has
staff been informed of these modified procedures?
At what times of the day are family members onsite, and how many are onsite at any one time? What locations in the facility do
family members visit or congregate in?
What type of documents will be accepted to establish client identity, especially for guest clients (e.g., driver’s license, State ID,
military ID, other picture ID)?
How will essential staff members be notified of the situation and their need to report for duty?
How will treatment records be maintained and accessed during a disaster? If primary avenues for record access are
inaccessible, what is the backup plan?
How will client direct fees be determined and collected? How will billing be conducted (e.g., Medicaid, insurances)?
How can crisis/relapse prevention counseling be provided? Are crisis phone lines available in the program, or can the program
request assistance from/referral to an existing hotline?
How will crisis/relapse prevention counseling be provided? How will the availability of this resource be communicated to
clients?
How will patients be assisted in accessing refills or replacements of prescribed or dispensed medications?
Which mutual-help groups will be available during or after a disaster? How can the program facilitate client use of these
groups as needed in disaster?
Is participation by staff in behavioral health response (e.g., crisis counseling teams) mandated? If yes, how many staff members
may be called offsite, what credentials and training are required for those staff members, and how will the essential functions
of staff members called offsite be covered?
How will care be provided to clients as they are relocated or transferred?
How will a system be implemented to reintegrate clients once the program resumes normal operations after disaster?
Other:
Continued on next page
 Worksheet B11 (page 2)
Outpatient Treatment Programs

Date(s) Addressed/ Planning Question

Updated
In a disaster situation, how will client needs be prioritized (those who are at substantial risk of substance use relapse or
psychiatric illness if treatment is discontinued, those who can tolerate interruption of treatment)?
Which clients are mandated for drug testing? How will drug testing for those clients be conducted under disaster-related
conditions? Are there existing Memoranda of Agreement (MOA) that will provide alternate and secured drug testing for clients
who cannot travel to the facility for this service? If yes, how will this information be communicated to clients?
Are the program’s doctors prescribing medications to any patients? How will patients who need refills obtain them? What
backup options/agreements have been established for medication refills if the program’s doctors are not available?
Can some clients be supported by telephone- or Web-based counseling? Have specific releases of information been
developed and put in place to support getting client authorization for Web-based counseling? Have these options, along with
their risks and benefits, been discussed with clients? What needs to be done to provide offsite support to clients?
What arrangements need to be made to ensure that clients have access to counselors in shelters or other locations?
What contracts or MOAs are in place to bring in additional medical assistance through professional staff-placing agencies in a
personnel shortage?
Have staff members discussed with clients what changes might occur during an emergency situation and how this may alter
how they would access services? Have clients been encouraged and directed to information that would help them prepare for
disaster?
Other:

Residential Treatment Programs

Date(s) Addressed/ Planning Question
Updated
In a disaster situation, which staff members will be responsible for determining status of patients (those who require continued
residential treatment, those who can be transferred or referred for treatment elsewhere, and those who can be discharged)?
How will parents/guardians of patients who are younger than 18 be notified of discharge or transfer plans? For patients older
than 18, how will family members or others involved with the patient’s care be notified?
How will emergency condition discharges be handled in terms of providing patients with take-home medications, instructions
for continuing care, and referral to outpatient treatment or mutual-help groups after the disaster has passed? Have specific

Appendix B—Worksheets
written or transfer instructions related to this type of discharge and follow-up been provided to the patients?
Has a list been developed of emergency housing and shelters that will be available in the community for patients who can
be safely discharged in a disaster if they have someplace safe to go? Does this list include contact information for these
resources? How will this list be updated?
Other:
Continued on next page
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Worksheet B11 (page 3)
Medical Detoxification
Date(s) Addressed/ Planning Question
Updated
In a disaster situation, how will patient status be determined (those who require continuing medical care, those who can be
transferred or referred for treatment elsewhere, and those who can be discharged)?
How can a specific treatment protocol of patients being detoxified be addressed and continued under emergency/disaster­
related conditions?
How can the specific needs of persons with physical or medical conditions that affect mobility or stability be addressed and
managed under emergency/disaster-related conditions?
How will parents/guardians of patients younger than 18 be notified of discharge or transfer plans? For patients older than 18,
how will family members or others involved with the patient’s care be notified?
How will emergency condition discharges be handled in terms of providing patients with take-home medications, instructions
for continuing care, and referral to outpatient treatment or mutual-help groups after the disaster has passed?
What facilities can take patients needing continuing medical care? How will those patients be transported? How will the
patients’ medical information be transferred?
How can assessment and intake be streamlined for intake during emergency conditions?
Other:

Opioid Treatment Programs (Note: See also Chapter 5, Management of Prescription Medications.)
Date(s) Addressed/ Planning Question
Updated
How many of the program’s current patients will likely need methadone dosing within 24 hours of a disaster incident?
How many patients will need refills of their take-home methadone doses and within what timeframe?
How much methadone will be needed onsite at any one time to provide take-home doses for all eligible patients in an
emergency?
How will dose information be accessed and maintained under emergency/disaster conditions?
How will methadone be transported to patients at other locations (e.g., jails)? Who will be responsible for this?
How will patients who are disabled or affected by communicable disease, such as influenza, be provided methadone?
In emergencies for which there is advance warning, can take-home doses of methadone be provided above the usual
quantities? If so, in what amounts? Can take-home privileges be extended to additional patients? If so, what will be the criteria?
How will lockboxes be provided, as required, to patients provided with new take-home privileges? Has the authority to make
these changes been documented fully?
How will exception requests (per Section 8.12 of 42 Code of Federal Regulations [CFR]) be submitted under various emergency
scenarios to the Substance Abuse and Mental Health Services Administration (SAMHSA) and the State Opioid Treatment
Authority (SOTA)?
Other:
Continued on next page
 Worksheet B11 (page 4)
Primary Prevention Services (Note: Primary prevention will not be an essential service in a disaster.)

Date(s) Addressed/ Planning Question

Updated
How will participants of nonessential services be notified of the cancellation of these services?
How will participants/clients be notified when regular services will be resumed?

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Worksheet B12 Requirements for Alternate Facilities
Name Date
Instructions: Use with Chapter 4, Continuity Planning. In the left column, list the behavioral health treatment program’s essential functions
(from Worksheet B8). In the middle columns, estimate the number of people involved in each essential function at any one time, and list facility
requirements to accommodate that number of people. Then, make a copy of this partly completed worksheet for every alternate facility being
evaluated. On each copy, write the prospective alternate facility’s name and contact information and indicate whether it meets the requirements.
Use the data collected to compare prospective alternate facilities and to consider how to meet requirements that an alternate facility cannot
provide.

Alternate Facility Name, Address, and Contact Information:

Number of Maximum Requirements: Estimate of needed floor space, furniture, beds Meets
Staff Members Number of (for male and female adults, adolescents, children), power, privacy, Requirements:
Essential Function To Perform Clients Served communications, security, storage, restrooms, meal preparation or
Function at any One Time serving areas, accessibility Yes or No
 Worksheet B13 Alternate Facility Arrangements by Disaster Scenario
Name Date
Instructions: Use with Chapter 4, Continuity Planning. For each disaster scenario, list the alternate facilities that have been arranged. Add any notes
(e.g., whether prearrangements have been confirmed, costs for use, distance from facility, whether some staff members will work from home). If the
program has multiple sites, a separate sheet should be completed for each noting the specific alternate arrangements. Memoranda of Agreement
(MOA) and/or prearrangements are recommended for external sites not owned by the program.

Primary Alternate Facility: Secondary Alternate Facility:

Disaster Scenario Name, Address, Contact Information, and Notes Name, Address, Contact Information, and Notes

Internal (only the behavioral health

treatment program site is affected)

Local (the program site and its

community are affected)

Regional or national (the

emergency affects a broad
geographical area)

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Worksheet B14 Checklist for Relocation Planning
Name Date
Instructions: Use with Chapter 4, Continuity Planning. Indicate by date when each planning step has been addressed or updated.

Date(s) Addressed/ Planning Step

Updated
Options for relocation of operations have been identified and confirmed through Memoranda of Agreement (MOA).
Written agreements have been made with transport companies that will be used, such as bus and van services to relocate
clients and staff.
A plan for triaging patients has been detailed (to identify those who are able to be discharged and relocate independently vs.
those who need further treatment or sheltering).
Multiple routes to each predetermined alternate site have been mapped. Routes have been marked on maps, which are kept
with the emergency supplies or in facility vehicles.
Disaster preparedness education and assistance, tailored to clients, have been provided.
Vehicles that will be used in emergency evacuation are kept in ready condition and fully fueled. Drivers have the appropriate
driver’s license for the vehicle and will have access to a credit card or cash in a disaster situation to pay for fuel as needed.
Primary and backup transportation options have been identified. Modes of transportation will accommodate clients being
moved who need special assistance (e.g., vans equipped for wheelchairs). The transportation plan considers the need to
move supplies including medications, computers, and so forth.
A chain of authority is established for ordering full-site relocation and indicating the all-clear (in coordination with local
emergency authorities) to return to the facility.
One or more staff members have been assigned closing and relocation tasks, such as (if time permits):
• Shutting down critical operations, including shutoff of utilities (e.g., gas or propane at main switches or valves,
disconnection of electric appliances, extinguishing woodstove fires).
• Transporting the emergency supplies.
• Transporting the facility go kit and emergency supply of medications.
• Transporting other critical equipment such as hard drives or servers.
• Locking doors and securing the building.
• Supervising logistics of transporting people and supplies.
• Taking a head count (using a prepared roster) of those relocating, and informing emergency authorities of those not
relocating or any missing persons and their likeliest locations.
• Coordinating with those in authority at the alternate site.
• Informing emergency authorities of the facility’s evacuation plan. (Confidentiality regulations may restrict the program from
providing authorities with the names of clients who were relocated.)
• Locking cabinets and safes that contain controlled substances and medical equipment, or arranging for their legal and
secure transfer.
Procedures are in place to inform the public of the facility’s evacuation and the location of the alternate facility (e.g., posted
signs on door, message on telephone answering machine, information posted to Web site and social media outlets).
 Worksheet B15 Checklist for Maintaining Communications With Essential Groups
Name Date
Instructions: Use with Chapter 4, Continuity Planning. For each essential group listed in the left column, place an X to indicate the means by which
communications will be maintained during an emergency.

GETS,
2-Way WPS, or Announcement
Cell Web Radio Satellite (outside Priority
Hotline Sign In- via Media
Group Landline Phone/ Site or or Listing Amateur Recorded on
Phone Smart- (social network Other
Intranet Walkie- Phone facility) for Radio Message Door Person such as Twitter,
phone Talkie Electric TV, radio)
Service*
Emergency
responders
Essential staff
Nonessential
staff
Clients
Client families
Substance
Abuse and
Mental Health
Services
Administration
(SAMHSA)
Drug
Enforcement
Administration
(DEA)
Vendors/
insurers
Providers of

Appendix B—Worksheets
mutual aid
GETS = Government Emergency Telecommunications Service; WPS = Wireless Priority Service
*
Continued on next page
109
110

Disaster Planning Handbook for Behavioral Health Treatment Programs

Worksheet B15 (page 2)

GETS,
2-Way WPS, or Announcement
Cell Web Radio Hotline Priority Amateur Recorded Sign In- via Media
Landline Phone/ Satellite (outside Listing
Group Site or or Message on (social network Other
Phone Smart- Phone Radio Person
Intranet Walkie- facility) for Door such as Twitter,
phone Talkie Electric TV, radio)
Service*
Referral
agencies
(e.g., service
agencies that
can assist
with other
emergency
needs)
Recovery
advocates and
groups
State disaster
behavioral
health
coordinator
State Opioid
Treatment
Authority
(SOTA)
Licensing
Entity
Funders
or billing
entities (e.g.,
Medicaid)
Media
Others:

GETS = Government Emergency Telecommunications Service; WPS = Wireless Priority Service

*
 Worksheet B16 Checklist of Records and Databases To Ensure Interoperable Communications
Name Date
Instructions: Use with Chapter 4, Continuity Planning. For each category of record or database listed in the left column, place an X to indicate
the options for retrieving or entering data. Also indicate the staff members who have authority to retrieve or enter data and whether they will have
access to the passwords or authentication procedures for accessing the record.

Portable Staff Members With Authority To Retrieve or

Category of Onsite Laptop
Offsite (battery Memory Device Copies in Enter Information and Who Have Access to
Record or Computer Server operated) (e.g., encrypted Paper Facility Other Passwords or Authentication Procedures for
Database flash drive, Go Kit Accessing the Record or Database
encrypted DVD)
Current client
medication
information
Other client
medical
information
Client
psychosocial
history
Client billing
information
Drug testing
data
Personnel
information
Payroll
Computer
systems
information
(network
diagram,
passwords)

Appendix B—Worksheets
Vendor
records
Other:
111
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Disaster Planning Handbook for Behavioral Health Treatment Programs

Worksheet B17 Checklist for Protecting Records and Databases
Name Date
Instructions: Use with Chapter 4, Continuity Planning. For each category of record or database listed in the left column, provide the information
requested in the other columns. Use this information to determine the steps to ensure protection of vital records and databases.

Form of Records/ Supporting Hardware/ Frequency

Category of Record or of
and Backup Means of Securing
Database Databases and Maintenance Other
Software Needed Protections Records/Databases
Location Backup
Client clinical information
Client billing information
Legal and financial records
(e.g., personnel, Social
Security)
Drug testing data
Personnel contact
information
Essential staff credentials
and State licenses
Payroll
Computer systems
requirements (e.g., network
diagram, passwords,
and keys; equipment
manufacturer, model, and
serial numbers; installation
procedures and licenses)
Software and hardware
operation manuals
Order of succession,
delegation of authority, and
Incident Command System
(ICS) structure
Other:
 Worksheet B18 Checklist for Managing Human Capital
Name Date
Instructions: Use with Chapter 4, Continuity Planning. Indicate by date when each staff policy has been addressed or updated.

Date(s) Addressed/ Maintaining Contact With Staff

Updated
A system has been developed for staff members to contact supervisors following a disaster to inform the program of their
status, location, and current contact information.
A system has been developed for the program to inform staff members of their work status (essential or nonessential) and
whether they are to report for work or to stay home.
Date(s) Addressed/ Work Schedules
Updated
Staff members have been preassessed for their capacity during an emergency (e.g., availability to work overtime, to stay onsite
as needed, to assume other or additional duties, to deploy to an alternate facility).
Staff functions that can be performed from home have been determined.
Methods of tracking and supporting staff members reassigned to work at an alternate facility have been developed.
Staff members have been assisted in preplanning alternate means and routes of transportation to and from work.
Date(s) Addressed/
Updated Compensation and Leave

Pay rates for disaster situations have been determined (e.g., when staff members take on additional duties, duties above their
current level, duties at alternate facilities, work overtime, or stay overnight at the facility).
A continuation plan has been determined for wages and salaries of employees who are unable to return to work immediately
following a disaster.
A plan for payment of salaries in disaster situations has been determined (e.g., a backup system is in place if the electronic/
direct deposit is not available for payroll).
Policies have been determined regarding whether staff members can take paid or administrative leave to stay home or
volunteer in the community recovery after a disaster.
Continued on next page

Appendix B—Worksheets
113
114

Disaster Planning Handbook for Behavioral Health Treatment Programs

Worksheet B18 (page 2)

Date(s) Addressed/
Staffing
Updated
Accommodations (e.g., day care) are available for essential staff members who have dependents and might be required to work
after business hours or when schools/day care facilities are closed.
Substitutes to fill essential positions have been identified from within the staff.
Outside substitutes have been arranged with another behavioral health treatment program under the terms of a mutual aid
agreement.
An alternate plan is in place to fill essential positions, such as by using a placement firm or by developing a list of on-call
temporary workers or volunteers (e.g., recent retirees).
A procedure is in place for checking the credentials and conducting background criminal checks if necessary of substitute
providers or volunteers brought on board immediately after a disaster.
Date(s) Addressed/
Training
Updated
Staff members have been assigned for training or credentialing in disaster response (e.g., National Incident Management
System [NIMS], Incident Command System [ICS]).
Staff members have been assigned for training in trauma-informed therapy (e.g., CPR, first aid, psychological first aid, grief and
bereavement counseling).
Staff members have been provided training to be culturally responsive to new populations that may seek services following a
disaster (e.g., people migrating from adjacent States or who have substance use disorders different from those typically treated
by the program).
Staff members who may be assigned to alternate facilities through a mutual aid agreement have been credentialed and
approved for that work.
Staff members have been selected and trained for participation on a behavioral health response team that may deploy into the
community.
Staff members who may be offered for mutual aid have been trained and credentialed for that work.
Staff members have been encouraged to develop home disaster plans.
Date(s) Addressed/ Staff Behavioral Health Needs
Updated
Staff members are trained to recognize the support needs of their colleagues and themselves during emergency response and
recovery phases.
Employment policies address leave for staff to access services for dealing with disaster-related behavioral health issues.
A list has been compiled of referral resources for staff members needing social services after a disaster (e.g., critical incident
stress debriefing; disaster recovery assistance with housing, insurance claims, workers’ compensation).
Policies are in place to support confidential self-referral or supervisor referral of staff members who are experiencing the need
for services to address stress and other reactions to disaster.
 Worksheet B19 Checklist for Management of Prescribed Medications

Name Date
Instructions: Use with Chapter 5, Management of Prescription Medications. Indicate by date when each planning step has been addressed or
updated.

Date(s) Addressed/ Planning Steps—All Programs

Updated
Clients have been advised on how to obtain prescription replacements and refills under various disaster scenarios.
Clients have been educated on what to carry with them when evacuating or seeking services at an alternate facility so that they
can obtain prescription replacement, refills, or methadone dosing.
The program has communicated with the public health department for information on the public stockpile of medications.
The topic of medication maintenance for clients has been addressed with local disaster planning committees.
Plans are in place for transfer and tracking of patients receiving medications to an alternate location or to another clinic that will
be able to provide guest dosing or other prescription medications.
Other:
Date(s) Addressed/ Planning Steps—Opioid Treatment Programs
Updated
Patient medical records (including dose levels and take-home privileges) are stored and regularly updated at a secure location
(e.g., an offsite server).
The opioid treatment program (OTP) is ready to quickly and securely transfer patient records and the supporting software to an
alternate facility.
The OTP is ready to submit exception requests to the Substance Abuse and Mental Health Services Administration (SAMHSA)
and the State Opioid Treatment Authority (SOTA) (as authorized).
The option of providing patients with smart ID cards has been considered. If smart ID cards are used, other OTPs have been
identified that have the equipment to read the cards and that can accept guest patients in emergency. A backup method for
transferring medical data has been established, in case patients lose their smart ID cards.
The program has discussed with its SOTA the capabilities of its central database and has determined the procedures for
accessing patient records in emergencies. Issues covered include:
• How patient information will be accessed when records at the program are destroyed or inaccessible.
• How information on guest patients from other OTPs will be accessed.

Appendix B—Worksheets
• How the OTP’s patient records will be accessed by other OTPs providing guest dosing.
• Whether patient releases and other permissions will be required to access patient records.
• Whether dosage information from guest patients will be relied on before verification of that information from the guest
patients’ home OTPs.
The program is aware of the current status of State-run healthcare communications systems through which dosing information
can be securely transferred.
Procedures are in place for handling patients who request courtesy dosing after a disaster and/or for referring prospective
115

guest patients elsewhere when the facility does not have the resources to handle those guest patients itself.
Continued on next page
116

Disaster Planning Handbook for Behavioral Health Treatment Programs

Worksheet B19 (page 2)

Date(s) Addressed/ Planning Steps—Opioid Treatment Programs (continued)

Updated
Procedures are in place for handling an influx of new patients after a disaster.
Procedures are in place for referring prospective pain patients to providers who can assist with pain management.
Program staff is aware of lawful procedures for moving controlled substances and the procedures for requesting moves.
The Drug Enforcement Administration (DEA) agent for the program’s jurisdiction has been informed about methadone
maintenance treatment and use of other controlled substances for behavioral health treatment and about the potential need
for expedited permissions in emergencies.
The local law enforcement agency has been advised that controlled substances are located on the property and has been
requested to provide the facility with high-priority protection if looting occurs following a disaster or with a police escort when
transporting program supplies to an alternate facility.
Contingency plans have been developed for resupply of methadone if the original supply becomes destroyed or inaccessible.
Counselors have discussed with physicians and pharmacies the options patients have to obtain prescription replacements and
refills under various scenarios (e.g., if patients cannot contact their prescribing physician, if their primary pharmacy closes, or if
they are relocated).
Counselors and/or OTP physicians provide education to patients on what to do to maintain supplies of their prescriptions.
Other:
 Worksheet B20 Disaster Plan Training and Testing Log
Name Date
Instructions: Use with Chapter 7, Completing, Testing, Activating, and Deactivating the Plan. List each training and testing activity in the left
column and details about that activity in the other columns.

Date Sponsor/Provider Department/Groups Number of

Training/Testing Activity Objective
Conducted (note credentials) Participating Participants

Appendix B—Worksheets
117
Appendix C—Abbreviations and Acronyms

AFC Access Family Care

CCC Citizen Corps Council

CCP Crisis Counseling Assistance and Training Program

CDC Centers for Disease Control and Prevention

CFR Code of Federal Regulations

COOP continuity of operations

CSAT Center for Substance Abuse Treatment

DATA Drug Addiction Treatment Act

DCM Disaster Case Management (Federal program)

DEA U.S. Drug Enforcement Administration

DHS U.S. Department of Homeland Security

DPT Division of Pharmacologic Therapies

DTAC Disaster Technical Assistance Center

ED emergency department

EHR electronic health record(s)

EMAC Emergency Management Assistance Compact

EMI Emergency Management Institute

EMR electronic medical record(s)

ESAR-VHP Emergency System for Advance Registration of Volunteer Health Professionals

ESF Emergency Support Function

FEMA Federal Emergency Management Agency

GETS Government Emergency Telecommunications Service

HHS U.S. Department of Health and Human Services

HIPAA Health Insurance Portability and Accountability Act

HIRA hazard identification and risk assessment

119
Disaster Planning Handbook for Behavioral Health Treatment Programs

HIT health information technology

ICS Incident Command System

KAP Knowledge Application Program

MMT methadone maintenance treatment

MOA Memorandum of Agreement (singular); Memoranda of Agreement (plural)

MOU Memorandum of Understanding (singular); Memoranda of Understanding (plural)

MRC Medical Reserve Corps

NDRF National Disaster Recovery Framework

NGO nongovernmental organization

NIMS National Incident Management System

OTP opioid treatment program

PAD psychiatric advance directive

POD point of distribution

PTSD posttraumatic stress disorder

QSOA qualified service organization agreement

SAAS State Associations of Addiction Services

SAMHSA Substance Abuse and Mental Health Services Administration

SBIRT screening, brief intervention, and referral to treatment

SERG SAMHSA Emergency Response Grant

SMA State Methadone Authority

SOTA State Opioid Treatment Authority

SSA Single State Agency

TAP Technical Assistance Publication

THIRA threat and hazard identification and risk assessment

VOAD Voluntary Organization Active in Disaster

WATrac Washington System for Tracking Resources, Alerts, and Communication

WPS Wireless Priority Service

120
Appendix D—Disaster Planning Web
Resources

Resources From the Substance Abuse and Mental Health Services

Administration (SAMHSA)
After the Crisis Initiative: Healing from Trauma after Disasters (provides information on
training people for peer support in and after disaster):
http://gainscenter.samhsa.gov/atc

Behavioral Health Treatment Services Locator:

http://findtreatment.samhsa.gov

Disaster Technical Assistance Center (provides access to technical assistance, resources

on preparedness and response, and a contact database of State and territory disaster
behavioral health coordinators):
http://www.samhsa.gov/dtac

Exception Requests (for the administration and management of opioid treatment):

http://www.dpt.samhsa.gov/regulations/exrequests.aspx

Federal Opioid Guidelines, April 2013:

http://www.dpt.samhsa.gov/pdf/FederalGuidelinesforOpioidTreatment5-6­
2013revisiondraft_508.pdf

Medication-Assisted Treatment:
http://dpt.samhsa.gov

Opioid Treatment Program Directory:

http://dpt2.samhsa.gov/treatment/directory.aspx

SAMHSA’s Disaster Behavioral Health Information Series Resource Collections (contains

themed installments of resources and toolkits in disaster behavioral health. Each
installment focuses on a specific population, disaster type, or other topic pertinent to
disaster behavioral health preparedness, response, and recovery):
http://www.samhsa.gov/dtac/dbhis

State Opioid Treatment Authorities:

http://dpt2.samhsa.gov/regulations/smalist.aspx

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Disaster Planning Handbook for Behavioral Health Treatment Programs

At-Risk Populations and Disaster

Health Information Translations: Quality Health Education Resources for Diverse Populations
(provides translations into multiple languages of disaster preparedness and response
information for clients), Ohio State University Medical Center, Mount Carmel Health System,
Ohio Health, and Nationwide Children’s Hospital:
https://www.healthinfotranslations.org/disaster-preparedness.php

National Council on Disability:

http://www.ncd.gov

National Resource Center on Psychiatric Advance Directives:

http://www.nrc-pad.org

Psychosocial Issues for Older Adults in Disasters, SAMHSA and the National Council on Aging:
http://store.samhsa.gov/shin/content//SMA11-DISASTER/SMA11-DISASTER-03.pdf

Special Populations: Emergency and Disaster Preparedness, National Library of Medicine,

National Institutes of Health:
http://sis.nlm.nih.gov/outreach/specialpopulationsanddisasters.html

Staying in Touch: A Fieldwork Manual of Tracking Procedures for Locating Substance Abusers
in Follow-up Studies (2nd ed.), University of California, Los Angeles, Integrated Substance
Abuse Programs (a model client locator form is located in Appendix A):
http://www.uclaisap.org/trackingmanual/manual/Tracking-Manual.pdf

Tips for People With Disabilities and Medical Concerns, Independent Living Resource Center of
San Francisco:
http://www.ilrcsf.org/wp-content/uploads/2012/09/Emergency-preparedness-for-people-with­
disabilities.pdf

Communications
Government Emergency Telecommunications Service, U.S. Department of Homeland
Security (DHS):
http://www.dhs.gov/government-emergency-telecommunications-service-gets

Wireless Priority Service, DHS:

https://www.dhs.gov/wireless-priority-service-wps

Electronic Health Records

Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs, Center for
Medicare & Medicaid Services (CMS):
https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html

Office of the National Coordinator for Health Information Technology, U.S. Department of
Health and Human Services (HHS):
http://www.healthit.gov

122
 Appendix D—Disaster Planning Web Resources

Emergency Planning for Staff and Clients

Basic Disaster Supplies Kit, Federal Emergency Management Agency (FEMA):
http://www.ready.gov/basic-disaster-supplies-kit

National Preparedness Month, National Child Traumatic Stress Network

(resources for families):
http://www.nctsn.org/resources/public-awareness/national-preparedness-month

Plan & Prepare, American Red Cross:

http://www.redcross.org/prepare

Ready.gov (consumer readiness Web site), FEMA:

http://www.ready.gov

Red Cross Mobile Apps:

http://www.redcross.org//prepare/mobile-apps

Federal Guidance and Support

Business (readiness Web page), FEMA:
http://www.ready.gov/business

Continuity of Operations, FEMA:

http://www.fema.gov/continuity-operations

Emergency Authorization for Disaster Relief—Domestic and International, Office of Diversion

Control, Drug Enforcement Administration:
http://www.deadiversion.usdoj.gov/disaster_relief.htm

Guidance on Planning for Integration of Functional Needs Support Services in General

Population Shelters, FEMA:
http://www.fema.gov/pdf/about/odic/fnss_guidance.pdf

Homeland Security Exercise and Evaluation Program, DHS:

https://www.llis.dhs.gov/hseep

Independent Study Program, FEMA (provides courses on topics including emergency

management, continuity of operations, and Federal guidance):
http://training.fema.gov/IS

National Disaster Recovery Framework, FEMA:

http://www.fema.gov/media-library-data/20130726-1820-25045-5325/508_ndrf.pdf

National Incident Management System, FEMA:

http://www.fema.gov/national-incident-management-system

National Preparedness Goal (1st ed.), FEMA:

http://www.fema.gov/pdf/prepared/npg.pdf

National Preparedness System, FEMA:

http://www.fema.gov/pdf/prepared/nps_description.pdf
123
Disaster Planning Handbook for Behavioral Health Treatment Programs

National Response Framework, FEMA:

http://www.fema.gov/national-response-framework

Planning & Templates, FEMA:

http://www.fema.gov/planning-templates

Survey & Certification—Emergency Preparedness, CMS (provides guidance for State Survey
Agencies and healthcare providers):
https://www.cms.gov/SurveyCertEmergPrep

Financial Aid for Programs

Crisis Counseling Assistance and Training Program (CCP), SAMHSA and FEMA:
http://store.samhsa.gov/shin/content//SMA11-DISASTER/SMA11-DISASTER-17.pdf

Disaster Loans, Small Business Administration:

http://www.sba.gov/category/navigation-structure/loans-grants/small-business-loans/
disaster-loans

Robert T. Stafford Disaster Relief and Emergency Assistance Act, as Amended,

and Related Authorities, FEMA:
http://www.fema.gov/pdf/about/stafford_act.pdf

Information for Medical and Health Professionals

Emergency Management Assistance Compact:
http://www.emacweb.org

NIDAMED (tools and resources that assist healthcare providers in identifying drug use early
and in referring patients to treatment):
http://www.drugabuse.gov/nidamed-medical-health-professionals

Public Health Mutual Aid Agreements—A Menu of Suggested Provisions, Centers for Disease
Control and Prevention (CDC):
http://www.cdc.gov/phlp/docs/Mutual_Aid_Provisions.pdf

Sample Qualified Service Organization Agreement:

http://www.lac.org/doc_library/lac/publications/QSO-BA%20Agreement%20Form.pdf

Screening, Brief Intervention, and Referral to Treatment (SBIRT), SAMHSA:

http://www.samhsa.gov/prevention/sbirt/

124
 Appendix D—Disaster Planning Web Resources

Pandemic Planning
Flu.gov—Know What To Do About the Flu, HHS:
http://www.flu.gov

IS-520: Introduction to Continuity of Operations Planning for Pandemic Influenzas (interactive

online course), FEMA:
http://training.fema.gov/EMIWeb/IS/IS520.asp

Seasonal Influenza (Flu), CDC:

http://www.cdc.gov/flu

Planning
Emergency Preparedness, Small Business Administration:
http://www.sba.gov/prepare

Public Health Practices: Enhancing Emergency Preparedness and Response, Center for
Infectious Disease Research & Policy, University of Minnesota:
http://www.cidrap.umn.edu/public-health-practices

Strengthening Emergency Response Through a Healthcare Coalition: A Toolkit for Local

Health Departments, Public Health—Seattle & King County:
http://www.apctoolkits.com/kingcountyhc/

Pre-Credentialed Volunteer Organizations

Citizen Corps:
http://www.ready.gov/citizen-corps

Emergency System for Advance Registration of Volunteer Health Professionals:

http://www.phe.gov/esarvhp/Pages/home.aspx

Medical Reserve Corps:

http://www.medicalreservecorps.gov

Voluntary Organizations
American Red Cross:
http://www.redcross.org

National Voluntary Organizations Active in Disaster:

http://www.nvoad.org

125
Appendix E—WATrac*

WATrac (Washington System for Tracking Resources, Alerts, and Communication) is a

web-based application serving the Washington healthcare system by providing two distinct
functions: 1) daily tracking of agency status and bed availability and, 2) incident management
and situational awareness during a disaster response.

The system provides a means for notifying healthcare partners of emergency incidents and for
supplying situational updates throughout the event. During an incident the daily facility status
and bed tracking feature not only provides emergency medical services (EMS) and hospitals
with patient transport information, but also automates the process for obtaining bed counts
for statewide updates. Command Center, for on-line chat and conferencing, provides an easily
accessible tool for real-time communication within agencies and between healthcare partners.

WATrac is web-based and will run on any computer with an internet connection, standard
web plug-ins, and Adobe Flash 10.0 or newer. The system meets HIPAA [Health Insurance
Portability and Accountability Act] security requirements by providing 128-bit encryption
for all transmitted data. Access to data is controlled by user permission groups, and strong
passwords can be required. The HIPAA requirement for recording who views, updates, or edits
records is met only by the Patient Tracking module. All other modules and features in WATrac
are not HIPAA compliant.

The WATrac application and data resides on servers in Minneapolis with back-up servers
containing duplicate data in Chicago. This service includes dynamic redirection in the event of
a server failure.

The Washington State Department of Health and participating regions, support statewide
implementation using federal funds. WATrac is administered and maintained as a
partnership between the Washington State Department of Health and Public Health—Seattle
& King County. A statewide Advisory Group made up of representatives from healthcare,
EMS, and public health provides direction and input for future use and implementation of the
WATrac system.

Full system access is currently available to hospitals, EMS, trial health, community health
centers, public health, nursing homes, and in-home service providers throughout Washington
State. Additional access is being guided by the WATrac Advisory Group and by resources and
staff availability.

For More Information

Email: [email protected]

Excerpted from Washington State Department of Health and Public Health—Seattle & King County (2012).
*

127
Appendix F—Sample Memorandum of
Agreement Between Opioid Treatment
Programs*
Note: This Memorandum of Agreement (MOA) is provided for example purposes only.
Programs should seek legal counsel before using or signing any legal document.

Continuity of care for patients of licensed opioid treatment program (OTP)

providers in times of emergencies

Between the following providers:

__________________________________________ (Licensed OTP Provider)

__________________________________________ (Licensed OTP Provider)

__________________________________________ (Licensed OTP Provider)

__________________________________________ (Licensed OTP Provider)

[add more lines as needed]

1 . Purpose

Each signing party of this MOA desires to voluntarily aid and assist one another by the
interchange of resources and services if an emergency or disaster should occur in which
a signing party cannot provide opioid replacement medication to all or a portion of its
patients. The signing parties agree that this MOA, however, will not create a legal duty to
provide assistance.

This memorandum defines the responsibilities of the parties and establishes a mechanism
whereby a licensed OTP provider (receiving provider) dispenses methadone or other

prescribed opioid replacement medication during an emergency on behalf of the OTP

provider in which the patient is enrolled (primary provider).

2 . Description

Licensed OTP providers enter into this MOA to provide prescribed opioid replacement
medication to enrolled patients in an emergency in which either provider cannot serve its
patients. Emergency circumstances include loss of power, structural damage to facility, fire,
flooding, or staff shortage.

*Adapted from an unpublished document provided courtesy of King County (WA) Healthcare Coalition.

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Disaster Planning Handbook for Behavioral Health Treatment Programs

The following are the minimum tasks that will be performed by the receiving provider when
the MOA is activated:

a. Provide short-term (30 or fewer consecutive days) methadone dosing of primary

provider’s patients.

b. For receiving providers who are licensed to dispense opioid replacement medication in
addition to methadone (e.g., buprenorphine), provide short-term (30 or fewer consecutive
days) dosing of prescribed opioid replacement medication to primary provider’s patients.

c. Document dispensing and treatment in accordance with county, State, and Federal
requirements.

d. Make best effort to verify patient’s dosage.

e. Make best effort to verify patient’s identity.

f. Within 90 days, communicate to primary provider information that is required (e.g.,

activity information, discharge data) for the State registry of OTP patients (if such
registry exists) and for State billing purposes.

g. Communicate to primary provider clinically significant information (e.g., recent history

of missed dosage, impairment, pregnancy, medication changes).

h. Dispense up to 30 mg of methadone to patient if verification of dosage is not reasonably

possible after best efforts to do so have been made.

i. Keep records of dispensing, including doses delivered and by whom, and submit them to
primary provider within 15 calendar days after services are rendered.

j. If operational, use [name of system being used to securely exchange information] to

assist with sharing patient data (e.g., identity and dosage verification) and clinically
significant information.

The following are the minimum tasks that will be performed by the primary provider when
the MOA is activated:

a. Make best effort to give receiving provider patient names, name of opioid replacement
medication prescribed, amount and date of last dosage, any other clinically significant
information, and additional information that will assist in verifying patient identity
(e.g., race/ethnicity, date of birth, last four digits of Social Security number).

b. Input required data into State registry of OTP patients if such registry exists.

c. Bill State of [name of State] or other funding source for services rendered to primary
provider’s patients by receiving provider while this MOA is activated.

d. Communicate to patients where to present for dosage and which documents and items
to bring (e.g., picture ID, pill bottle, prescription).

130
 Appendix F—Sample Memorandum of Agreement Between Opioid Treatment Programs

e. Deploy clinical or administrative staff from the primary agency to the receiving agency
when requested by the receiving provider for activities such as dispensing, counseling,
and other medical care.

f. Make best efforts to transport opioid replacement medication and a completed Drug
Enforcement Administration Form 222 from primary provider’s supply to receiving
agency.

g. If operational, use [name of software being used to securely exchange information] to

assist with sharing patient data (e.g., identity and dosage verification) and clinically
significant information.

3 . Activation and Deactivation

This MOA shall become effective immediately on its execution by the signatory providers’
respective executive directors or designees. This MOA is activated by written or oral
notification by the primary provider’s executive director or his/her designee to the receiving
provider’s executive director or his/her designee and by written or oral communication by
the receiving provider of activation of the MOA. Activation of this MOA may occur at any
time, day or night, including weekends and holidays.

Mutual aid shall continue to be available until participation in activation is terminated in

writing by the withdrawing parties. The receiving provider agrees to give reasonable notice
to the primary provider before withdrawing assistance.

4 . Terms and Termination of MOA

a. This MOA shall be in full force and effect from date of execution [date] through ending
date [date] but will be renewed automatically unless terminated pursuant to the terms
hereof.

b. Signing parties may terminate this MOA with written notification to the other signing
parties no less than 30 calendar days in advance of the termination date.

c. The receiving provider’s clinical personnel who care for primary provider’s patients
must be in good standing with the receiving provider and be current on all requisite
licensing and permitting.

d. The receiving provider and its participating personnel must abide by all Federal, State,
and local laws.

e. The primary and receiving providers must ensure that detailed records of expenditures
and time spent by deployed staff are complete and accurate and have adequate
supporting documentation.

5 . Employees

If the receiving provider requests clinical or administrative staff members from the primary
provider, employees of a primary provider shall at all times while providing assistance
continue to be employees of the primary provider. Wages, hours, and other terms and
conditions of employment of the primary provider shall remain applicable to all of its
employees who provide assistance under this MOA. The primary provider shall be solely

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Disaster Planning Handbook for Behavioral Health Treatment Programs

responsible for payment of its employees’ wages, required payroll taxes, and benefits or
other compensation. The receiving provider shall not be responsible for paying wages,
benefits, taxes, or other compensation to the primary provider’s employees.

Each party shall pay workers’ compensation benefits to its own injured personnel, if such
personnel sustain injuries or are killed while rendering aid under this MOA, in the same
manner and on the same terms as if the injury or death were sustained serving its own
patients. Nothing in this MOA shall abrogate or waive any party’s right to reimbursement
or other payment available from any local, State, or Federal government or abrogate or
waive the effect of any waiver, indemnity, or immunity available to a party under local,
State, or Federal law or other governmental action. To the extent that such reimbursement,
payment, waiver, indemnity, or immunity does not apply, then each party shall remain
fully responsible as employer for all taxes, assessments, fees, premiums, wages,
withholdings, workers’ compensation, and other direct and indirect compensation, benefits,
and related obligations with respect to its own employees. Each party shall provide workers’
compensation in compliance with the statutory requirements of the State of [name of State].

6 . Cost and Method for Reimbursement

a. The receiving provider must submit to the primary provider complete and accurate
documentation of services rendered to patients of the primary provider, which include
dispensing records and an invoice, within 15 calendar days after rendering services.

b. On receiving complete and accurate documentation from the receiving provider

and agreement of invoice, the primary provider will submit documentation for
reimbursement at the Medicaid rate at time of service to the State of [name of State] or
other funding source as applicable.

c. The primary provider will reimburse the receiving provider within 15 calendar days of
receiving payment from the State of [name of State] or other funding source.

d. If the primary provider has not reimbursed the receiving provider within 15 calendar
days, the receiving provider can allow a 45-day grace period to the primary provider.
At the end of the grace period, the receiving provider may take appropriate action to
pursue reimbursement.

7 . Contract Claims

This MOA shall be governed by and construed in accordance with the laws of the State of
[name of State] as interpreted by the State of [name of State] courts. However, the parties
may attempt to resolve any dispute arising under this MOA by any appropriate means of
dispute resolution.

8 . Acceptance of Agreement

Providers offering to enter into this MOA shall fully complete this MOA with the

information requested herein and sign two originals of a fully completed MOA. Each

provider will keep one of the original MOA.

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 Appendix F—Sample Memorandum of Agreement Between Opioid Treatment Programs

In addition, a copy of the MOA, signed and fully completed by the providers, shall be faxed
or sent to:

To: [Insert the name, address, and contact information including fax number for outside
party location, such as the Single State Agency for Substance Abuse.]

As noted by the providers’ signatures (below), the providers agree to the terms
and conditions as set forth in this MOA and agree to abide by the requirements for
reimbursement. All amendments to this MOA must be in writing and agreed to by both
providers.

OTP provider [Insert the following information for each party to the MOA]:

Company Name _____________________________________________

Business Address _____________________________________________

Phone No. _____________________________________________

Fax No. _____________________________________________

Email Address _____________________________________________

After-hours emergency contact information:

Contact Name _____________________________________________

Phone No. _____________________________________________

Fax No. _____________________________________________

Cell No. _____________________________________________

Email Address _____________________________________________

Signature of Chief Executive _____________________________________________

Printed Name _____________________________________________

Title _____________________________________________

Date _____________________________________________

133
Appendix G—Editorial Board

and Field Reviewers

Editorial Board Thomas R. Franz

Assistant Director, Behavioral Health
Ron Jackson, M .S .W . Disaster Services
Executive Director Mental Hygiene Administration
Evergreen Treatment Services State of Maryland Department of Health and
Seattle, Washington Mental Hygiene
Jessup, Maryland
Elizabeth Ludeman-Hopkins, M.P.A., CAC
Performance Improvement Director Chance A . Freeman
Central Virginia Community Services Branch Manager
Lynchburg, Virginia Disaster Behavioral Health Coordinator
Disaster Behavioral Health Services
Jane Maxwell, Ph .D .
Mental Health and Substance Abuse Division
Senior Research Scientist
Texas Department of State Health Services
Addiction Research Institute
Austin, Texas
University of Texas
Austin, Texas John Lowe, RN, Ph.D., FAAN
Associate Professor
Michelle McDaniel, M .B .A ., M .H .P .
Christine E. Lynn College of Nursing
Emergency Preparedness Planning Manager
Florida Atlantic University
Public Health—Seattle and King County
Davie, Florida
Seattle, Washington
Michael Lynde
Deborah Podus, Ph .D .
Program Director
Associate Research Sociologist
New Freedom Center
Semel Institute for Neuroscience and Human
Bismarck, North Dakota
Behavior
UCLA Integrated Substance Abuse Programs Rodrigo Monterrey
David Geffen School of Medicine at UCLA All-Hazards Coordinator/Substance Abuse
Los Angeles, California Disaster Coordinator
Bureau of Substance Abuse Services
Massachusetts Department of Public Health
Field Reviewers Boston, Massachusetts
Laura J. Copland, M.A., LCMHC (NH)
Paul Nagy, M.S., LPC, LCAS, CCS
Director, Behavioral Health Disaster Services
Director of Clinical Consultation and
and Veterans Reintegration Issues
Training
State of Maryland Department of Health and
Duke Addictions Program
Mental Hygiene
Duke University Department of Psychiatry
Jessup, Maryland
and Behavioral Sciences
Michael Duffy, RN, CD Duke University
Programing Consultant Durham, North Carolina
Michael Duffy Consulting
Little Elm, Texas

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Disaster Planning Handbook for Behavioral Health Treatment Programs

Amy B. Smith, LPC, MAC, NCC, SAP Katie Wells, M .P .A ., CAC III
Capital Counseling Services Manager, Adolescent Substance Use Disorder
Washington, District of Columbia Programs
Division of Behavioral Health
Kathyleen M . Tomlin, M .S ., CADC III Denver, Colorado
Private Practice Consultant & Counseling
Supervision Ednita M. Wright, Ph.D., LCSW, CASAC
Cheyenne River Training and Consulting Associate Professor
Portland, Oregon Human Services/Teacher Education
Department
Cynthia Moreno Tuohy, NCACII, Onondaga Community College
CCDCIII, SAP Syracuse, New York
Executive Director
NAADAC, the Association for Addiction
Professionals
Alexandria, Virginia

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Appendix H—Acknowledgments

Numerous people contributed to the development of this Technical Assistance Publication

(TAP), including the Editorial Board and field reviewers (see Appendix G).

This publication was produced under the Knowledge Application Program (KAP), a Joint
Venture of The CDM Group, Inc., and JBS International, Inc. (JBS), for the Substance Abuse
and Mental Health Services Administration, Center for Substance Abuse Treatment.

Lynne MacArthur, M.A., A.M.L.S., served as the JBS KAP Executive Project Co-Director, and
Barbara Fink, RN, M.P.H., served as the JBS KAP Managing Project Co-Director. Other JBS
KAP personnel included Catherine Baker, M.Ed., Writer; Wendy Caron, Quality Assurance
Editor; and Suzanne Garber, M.A., Quality Assurance Editor.

137
Technical Assistance Publications (TAPs) include:

TAPs 1–18, 20, 23–27 are no longer available.

TAP 19 Counselor’s Manual for Relapse Prevention With Chemically Dependent Criminal Offenders

TAP 21 Addiction Counseling Competencies: The Knowledge, Skills, and Attitudes of Professional Practice

TAP 21-A Competencies for Substance Abuse Treatment Clinical Supervisors

TAP 22 Contracting for Managed Substance Abuse and Mental Health Services: A Guide for Public Purchasers

TAP 28 The National Rural Alcohol and Drug Abuse Network Awards for Excellence 2004, Submitted and
Award-Winning Papers

TAP 29 Integrating State Administrative Records To Manage Substance Abuse Treatment System Performance

TAP 30 Buprenorphine: A Guide for Nurses

TAP 31 Implementing Change in Substance Abuse Treatment Programs

TAP 32 Clinical Drug Testing in Primary Care

TAP 33 Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment

TAP 34 Disaster Planning Handbook for Behavioral Health Treatment Programs

TAPs may be ordered or downloaded from SAMHSA’s Publications Ordering Web page at
http://store.samhsa.gov. Or, please call SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727) (English and Español).
HHS Publication No. (SMA) 13-4779
Substance Abuse and Mental Health Services
Administration
Printed 2013