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05 / 04 / 2022 16 : 12 FAX 2094732214 DAVITA la0010 / 0010 Facility Incident Management Tool Event Checklist Fi /\Z/-! R ( i <} l J $ (� /\'j (Zl /_\ �� ❑ Refer to Compliance transportation policy Procedure Patient relocation ❑ Dial 911 , as applicable ❑ Review with local leadership ❑ Always follow the direction of local ❑ Refer to section Patien Transfer_/ Emergency Management, emergency Relucotion for additional requirements services, and public health personnel El Place signage on front door of facility r=lf_" lity MifST adhere to facaf evtiCtcatie;n with relocation facility information csrctc;r ❑ Contact Home modality patients with Situation assessrhent back up facility and on- call information ❑ Is situation immediate or forecasted ? Communication Where is it located ? ❑ Medical Director ❑ What is the level of contamination LlLocal leadership team associated with the event? ❑ DaVita Guest Services ( DGS) at (800) ❑ Large or small scale? 400- 8331 ❑ Duration? One day or multiple days? ❑ Area Risk Manager Communicate to everyone in building ❑ Media refer to Village Communications ❑ Situation that has occurred Documentation ❑ Actions to be taken ❑ Document event and facility action o Risk Event Management (REM ) If situation outside is deemed unsafe o Governing Body ❑ Dial 911 , as applicable o Facility Health Record ( FHR) ❑ Communicate with everyone within facility Water testing ❑ Do not exit facility, shelter in place ❑ Determine appropriate water testing ❑ Turn of HVAC system, if potential of requirements based on nature of event affecting air within facility ❑ Refer to appropriate policy based on equipment Discontinue patient treatments ❑ Review plan of action with Medical Immediate emergency Director ❑ Patient emergency take off procedures performed, as per policy 1_._10-09. Hemodialysis equipment a _erri�irtnticm ,�f Dialysis in. o) Ei ieillr;gency ❑ Actions based on severity of event ❑ Aid patients who require assistance ❑ Refer to appropriate policy based on Not immediate emergency equipment ❑ Discontinue treatments standard ❑ Additional testing at discretion of procedure Biomedical and Clinical Services dependent on situation. Evacuation of facility ❑ Documentation and any closure dates are Only if requested by emergency services maintained on appropriate monitoring :1 Follow facility evacuation plan logs, i . e. , Water Treatment logs, Reuse D Teammates assume established logs, Refrigerator logs, etc. evacuation assignments 7 Aid patients who require additional Additional actions may be;require l ,' assistance ID Refer to POS;i= 1�VENT section 7 Verify everyone has evacuated Take Emergency Supply Kit to designated evacuation assembly area J Provide necessary medical attention )OST:'EVENT ' 'atient assessment ] Assess medical needs of all patients involved in incident 7 Work with Medical Director to establish treatment priority and identify high risk patients ome modalities J Communicate current situation Assess need for in -center treatment and alternate backup facility Review any current water advisories and safety processes Review supplies on hand Emergency diet tient transportation Initiate standard transportation process Alternate transportation may be required ge 14 of 48 Internal Use Only DaVita Emergency Management rsion 6/7/2021 Property of DaVita Inc. Confidential and Copyrighted ©2021 ReceivedTir�ie .. May 4 .. . , 2022 43 56PM No , 7188 . ,: , . .