County of Sacramento California*

R1

The county must make the completion of the Flood Annex to its All Hazards Emergency Operations Plan a matter of high priority. Response Concur. The flood annex is a high priority for the Emergency Operations Office, and is currently in review for a fall completion. RESPONSE TO THE 2005-06 GRAND JURY FINAL REPORT August 7, 2006

R2

The Sheriff's Department should, by August 2006, complete the development of standard operating procedures for a mass evacuation due to a flood disaster. This should include plans for the evacuation of the medically or mentally infirm due to age or disability. Sheriff Response The Sacramento County Sheriff's Department concurs with this recommendation. A working group, chaired by the Director of Emergency Operations Office (Rick Martinez) is currently undertaking the task of developing the County Evacuation Plan. The working group is comprised of the American Red Cross, the Sheriff's Department, California Highway Patrol, Cal Trans, Sacramento County Public Health, Sacramento Police Department, Regional Transit, Para Transit and the Governors' Office of Emergency Services. The Sacramento County Sheriff's Department will develop internal Policies and Procedures to match recommendations proposed by the working group. Emergency Operations Response Concur with the exception of completion date. A draft Evacuation Annex to the County's All Hazards Emergency Operations Plan has been developed and is being coordinated with a working group to clarify roles and responsibilities among response agencies and develop response processes to address evacuation of the medically or mentally infirm due to age or disability. Emergency Operations intends to develop an advisory committee of representatives from groups representing vulnerable populations to review and provide input to the evacuation plan. With this input, the plan will be completed as soon as practically possible. Emergency Operations received approval for an augmentation of $150,000 to contract for a consultant to develop elements necessary to address the County's special needs preparedness/care and shelter planning. In addition the consultant will incorporate these issues into our local evacuation plan and regional mass evacuation plan.

R3

The county should develop and maintain a comprehensive database for the location and telephone numbers of skilled nursing facilities, assisted living facilities, board and care facilities, home health care and hospice agencies, senior centers, veterans homes, group homes for the mentally ill, client providers for persons with identified special needs, and other congregate care facilities, including numerous state licensed small scale adult day health care centers, in order to facilitate emergency communication directly or through such agencies in the event of a flood. For this purpose, each such provider or facility should be required to maintain a current list of client telephone numbers and addresses. Emergency Operations Response Concur. Currently, there is not a database in the County which contains this type of information. A portion of recently approved funding for special needs evacuation planning will be used to initiate the collection of service provider information and to contact regulatory agencies to determine whether providers are or can be required to maintain current contact lists for their clients. Methods and costs of establishing the database and long term maintenance of the database will need to be explored and appropriate funding provided for this recommendation to be successful. The project will begin this winter. DHHS Response Concur in principle. This recommendation is consistent with the approach that Public Health recommends for reaching special needs populations. Public Health, in the process of developing its own risk communication plan, has identified a number of such key contacts, but recognizes that a complete listing is likely to include numerous additional entities. The overall responsibility to maintain this database most appropriately rests with the Emergency Operations Office. Public health administers an emergency alerting system (CAHAN) for notification of key government and other entities with responsibilities in emergency response. Enrollment of users is ongoing and increasingly including non-government entities, such as schools, home health RESPONSE TO THE 2005-06 GRAND JURY FINAL REPORT August 7, 2006 agencies, and hospitals. This tool would enable the County to rapidly issue alerts and instructions on how to safeguard clients in disaster conditions. Whether the County can actually require (versus request) a facility to maintain a list of clients and telephone numbers will depend on its regulatory oversight authorities. The county does not have regulatory oversight of these facilities. The regulatory oversight rests with the State. Sheriff Response The Sacramento County Sheriff's Department concurs in principle with this recommendation. Currently there is not a database in the County which contains this type of information. It is recommended that a funding augmentation from the County Board of Supervisors be proposed to fund and develop a team that would be responsible for creating, updating and maintaining the database with this information. No timeline has been set for the drafting of this proposal.

R4

The County should secure and distribute to all pertinent public and private agencies a formal opinion of the Sacramento County Counsel and/or the Attorney General on the effect of HIPAA upon the sharing of lists of such information in the event of an imminent disaster. Emergency Operations Response Concur with Department of Compliance response. Department of Compliance Response The Department of Compliance, Office of HIPAA has requested a formal opinion from County Counsel regarding the sharing of protected health information in the event of an imminent disaster. Upon receipt of the legal opinion, a determination will be made regarding its distribution. Because County Counsel legal opinions apply only within the County of RESPONSE TO THE 2005-06 GRAND JURY FINAL REPORT August 7, 2006 Sacramento's legal entity, the value of disseminating such an opinion, other than for information, must be evaluated.

R5

The county should require training for managers and staff of private care facilities and agencies, along with formalized agreements specifying the roles and responsibilities of such facilities and agencies in the event of a flood. Emergency Operations Response Concur with the need for required training and a better understanding by care facilities of their roles and responsibilities in the event of a flood. However, there is no legal mandate to require staff of private care facilities and agencies to comply with a training requirement. A portion of recently approved funding for special needs evacuation planning will be used to coordinate with regulatory agencies and care facilities to encourage cooperation with a training program and to develop the understanding of care facilities regarding their roles and responsibilities in the event of a flood. Clarification of the legal responsibilities of care facilities and the role of the regulatory agency in compliance is needed prior to consideration of formalized agreements between the county and care facilities.

R6

The County should secure or contract for immediate access to a determined number of emergency ready, fully staffed and equipped specialized transportation vehicles, for the transportation of persons with special needs to appropriate shelters or in-kind facilities within the region. Emergency Operations Response Concur. Agreements for immediate access to emergency ready specialized transportation vehicles are already in place.

R7

RESPONSE TO THE 2005-06 GRAND JURY FINAL REPORT August 7, 2006 The county should identify the local hospital surge capacity under various circumstances of a flood disaster, and provide for alternate care sites for special needs persons who might otherwise require hospitalization. Emergency Operations Response Concur with DHHS response. DHHS Response Do not concur. The responsibility for planning for alternate care sites outside of hospital has been ٠ unclear. In recent Pandemic Influenza grant guidance, Public Health has been tasked to plan in this area, at least to the extent of identification of potential sites. Actual implementation of alternate care sites requires much more than site selection and must involve entities experienced in operation of direct patient care healthcare services. This includes identification of properly credentialed and trained healthcare staff, appropriate medical direction, acquisition of equipment supplies, and more. To assign this responsibility to Public Health entities that normally are engaged in communicable disease investigations and surveillance of community-wide disease patterns through surveillance data represents a major paradigm shift and requires substantial commitment of resources. It would also require the hiring of additional staff with qualifications in this area. In addition, guidelines and standards for operating alternate care settings remain in development at the State level and are needed as a basis for local planning. The State of California, in its proposed 2006-7 budget, indicated its intent to purchase up • to three mobile hospital facilities, each of which could provide for the care of up to 250 individuals. This resource will presumably be available to deploy to any area in the state affected by floods or other disasters. Public Health and the Sacramento Regional Medical Reserve Corps continue to ٠ coordinate planning in anticipation of the possible mobilization of volunteer health professionals needed to staff alternate care facilities. Information has been obtained regarding the US Public Health Service's Federal Medical • Stations, which are pre-trained, deployable medical units able to staff medically-fragile shelters. The physical site and other support requirements necessary to support such a unit, if requested to respond to the Sacramento Area, are under review so that planning can anticipate those needs and facilitate a Federal response, if needed. Public Health, Sacramento area hospitals, and the Northern and Central California ٠ Hospital Council are currently in the process of selecting and contracting with a consultant to develop a coordinated regional hospital plan intended to maximize the available medical surge capacity through efficient use of local resources. The scenarios on which the planning will be based include pandemic influenza and floods. HRSA hospital preparedness funds, which are distributed locally through the Public Health Division are being utilized to fund this project. RESPONSE TO THE 2005-06 GRAND JURY FINAL REPORT August 7, 2006

R8

The county should provide, reserve, staff, and equip one or more shelters for the special needs of the medically or mentally infirm due to age or disability. Emergency Operations Response Concur with DHHS response. DHA Response The Department of Human Assistance agrees with the response provided by the Department of Health and Human Services. DHHS Response Under the leadership of the Emergency Operations Office, a multidisciplinary task force consisting of Emergency Operations, American Red Cross, Animal Control Services, Department of Human Assistance and Public Health are currently in the process of conducting assessment of potential sites throughout the county that could serve a variety of emergency response functions. These potential functions include general shelters, shelters able to accommodate domestic pets, special needs shelters (medically fragile, people with disabilities), alternate medical treatment sites, and mass prophylaxis clinics. Following collection of site assessment data, the next step will be to determine the suitability of each site for any of the proposed purposes. That information will be kept with Emergency Operations so that sites can be appropriately selected (through the County Emergency Operations Office or Emergency Operations Center, if open) and activated in response to a disaster. It is anticipated that MOUs will be developed between the County and each site in order to facilitate activation for any of the proposed purposes. RESPONSE TO THE 2005-06 GRAND JURY FINAL REPORT August 7, 2006

R9

County, city, and other local agency employees are designated by law as disaster services workers, and may be assigned to such efforts, including evacuation and care of the special needs populations, in the event of a major emergency evacuation. Those who are able and competent to do so should be identified, organized and trained in advance of a major emergency. Emergency Operations Response Concur with the need to train all county employees to a basic level of understanding of emergency response systems including NIMS and SEMS, and on personal disaster preparedness and their potential role as emergency services workers per County Ordinance. When appropriate, additional training should be provided to those employees who are designated to respond during emergencies. To establish a comprehensive training and preparedness program for all local government employees, the county, cities and special districts would need to evaluate the capabilities of personnel, needs of the emergency response organization and best use of available personnel to determine what level of training is needed and how best to deploy trained employees during emergencies. Appropriate policy direction, staffing and funding would be necessary to implement a comprehensive program county-wide. The county recognizes, values and plans to integrate volunteer groups, community based organizations and other trained groups to provide assistance to first responders and emergency managers during emergencies. Groups such as the Medical Reserve Corps, Community Emergency Response Teams (CERT), and neighborhood associations can augment response capabilities. RESPONSE TO THE 2005-06 GRAND JURY FINAL REPORT August 7, 2006 DHHS Response Concur. Current planning within DHHS requires divisions and programs to identify the capabilities of staff to serve in emergency response roles. This is a fluid situation given the turnover of staff. However, a system is in place which would enable a rapid inventory of available staff at the program level in order to respond through the chain of command to personnel resource requests. Resources for pre-training of staff are insufficient to achieve this goal for the range of possible assignments. Grant-funded programs cannot readily free staff to participate in such training without sustained significant revenue losses. Currently, the minimum requirement to arrange for NIMS training on a county-wide basis to meet a September 2006 deadline cannot be readily met within available resources, let alone additional training for specific job functions. As an alternative to advance training, Public Health developed a format and model materials to conduct "Just-in-Time training" for personnel assigned to support a mass prophylaxis clinic.

R10

The County should refocus its efforts on public awareness, education, and promotion of effective personal, household, and local community plans for self-help and mutual assistance that would RESPONSE TO THE 2005-06 GRAND JURY FINAL REPORT August 7, 2006 include the designation of contact monitors for each person with special needs, in the event of a major emergency evacuation. Emergency Operations Response Concur. Public outreach, especially to vulnerable populations, has been a high priority since Hurricane Katrina, but more needs to done. Additional staffing and funding are needed for an effective and ongoing public education program, especially in the area of assisting vulnerable populations to prepare for evacuation. Sheriff Response The Sacramento County Sheriff's Department concurs with this recommendation. The Sheriff's Department and the Emergency Operations Office developed partnerships with the Sacramento County Department of Health and Human Services and UC Davis Hospital to develop educational brochures to increase the preparedness of our community. The Sacramento Region Citizen Corps Council and the Emergency Operations Office participated in the distribution of these brochures and the electronic versions of this publication are available on the Public Health and Sacramento Region Citizen Corps web sites. The Sacramento Regional Office of Homeland Security and the Sacramento Region Citizen Corps Council have trained approximately 125 citizen volunteers in a Train the Trainer course to assist in the delivery of public education materials to the communities in our region. In Partnership with the Emergency Operations Office, on-going public outreach is being coordinated by the Sacramento Region Citizen Corps Council with the goal of reaching 15% of our 1.3 population by May 2008. DHHS Response The County is mindful of the need for this type of awareness education and efforts have been undertaken to address this need within the available resources. • In partnership with UC Davis, the County participated in the development of a disaster guide entitled, "Are you prepared?" • Public Health grant funds were used to print approximately 120,000 of these guides.