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Indiana Federation of Ambulatory Surgical Centers

Emergency Preparedness

The Indiana Federation of Ambulatory Surgical Centers, in collaboration with Vantage Point Consulting, has developed a comprehensive Emergency Preparedness Toolkit in an effort to assist ASCs in meeting the regulatory requirements established by the Indiana State Department of Health (ISDH), Centers for Medicare and Medicaid Services (CMS), Healthcare Facilities Accreditation Program (HFAP), Accreditation Association for Ambulatory Health Care (AAAHC), and Joint Commission (TJC).

The toolkit below includes ASC-specific emergency and continuity-of-operations policy templates, exercise scenarios, Incident Command documentation, and risk assessment reference materials. For questions, comments, or concerns regarding the contents of this toolkit, please contact the IFASC Emergency Preparedness Coordinator.

Shelby Brouillette, RN, BSN
Emergency Preparedness Coordinator
(W): 765-474-7838
(C): 765-418-7472


Table of Contents

Emergency Preparedness Documents

Please Note: Most of the following documents will need to be downloaded to view.

  1. ASC Emergency Preparedness Program
  2. ASC Emergency Preparedness Program Administrative Instruction Manual
  3. ASC Emergency Operations Plan
  4. Policies and Procedures
    1. Emergency Operations Plan
      1. HVA
      2. ASC HVA Tool
      3. Alternate HVA Tool
    2. Communications Plan
      1. Staff Contact List
      2. HCC and Local Contact List
      3. EMA/HCC Communication Document
      4. Transfer Agreements
    3. Emergency Tracking Policy
    4. Evacuation Policy
      1. Evacuation Map
    5. Shelter In Place Policy
      1. Resource Inventory
    6. Medical Documentation Policy
      1. Backup Medical Record Documentation
    7. Utility Systems Failure Policy
    8. Volunteer Management Policy
    9. Alternate Role of ASC Policy
      1. Alternate Care Site Agreement
  5. Incident Command System
    1. Command Job Action Sheets
    2. Succession Plan
    3. Small Organization ICS Team Chart
    4. HICS Job Action Sheets
    5. Quick Start Guide
    6. HICS Activity Log
    7. Facility System Status Report
    8. Disaster Victim Patient Tracking
    9. Master Patient Evacuation Tracking
  6. Exercise Development Guide
    1. Exercise Development Guide
    2. After Action Report
    3. Exercise Scenarios and Critiques
    4. Water Main Break
    5. Utility Failure
    6. Tornado
    7. Severe Weather
    8. Infectious Disease
    9. Earthquake
    10. Active Shooter
    11. Information Technology/Communication Drill
    12. Mass Casualty Guide
    13. Hazardous Materials
    14. Straight-line Winds/Facility Damage
    15. Suspicious Package
    16. Aggressive Patient
    17. Internal Flood
    18. External Flood
    19. Vehicle Into Structure
    20. Drug Seeking Emergency
    21. Escalating Workplace Violence
    22. Cyber Intrusion Incident
  7. Life Safety
    1. Interim Life Safety Policy
    2. Above Ceiling Work Permit Policy
    3. Above Ceiling Work Permit
    4. ASHE Wet Location Assessment Tool
    5. Fire Prevention Policy
    6. Fire Watch Policy
    7. Fire Extinguisher Inspection
    8. Fire Door Inspection
    9. ISDH-CMS Life Safety Tag Listing
    10. ASC Life Safety Survey Doc
    11. ASC Life Safety Entrance Checklist
    12. Hot Work Permit
  8. Emergency Preparedness Infection Control
    1. Pandemic Policy
    2. Infection Control Risk Assessment Policy
    3. Legionella Policy
  9. ISDH Resource Center