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DHHS POLICIES AND PROCEDURES

________________________________________________________________________________________________________________

Section V:

Human Resources

Title:

Safety and Benefits

Chapter:

Active Shooter Preparedness & Response

Current Effective Date:

5/1/16

Revision History:

 

Original Effective Date:

5/1/16

________________________________________________________________________________________________________________

Purpose

The purpose of this policy is to coordinate and provide guidelines for the implementation of an Active Shooter preparedness and response procedure for the Department of Health and Human Services.

Policy

It is the policy of the Department of Health and Human Services (DHHS) to provide a safe workplace for employees, patients, residents, clients, visitors, and any other individuals present in DHHS facilities. In order to preserve life in the event that an active shooter threatens or appears to be actively engaged in killing or attempting to kill people in a DHHS facility, the following guidelines have been established to maximize survivability.

Scope

This policy is applicable to all divisions, facilities, and offices within the Department of Health and Human Services. This plan shall be used by all DHHS facilities/divisions unless a site-specific plan has been developed. Site-specific plans must be submitted to and approved by the DHHS Safety Programs Manager.

Definitions

Active Shooter: A person who appears to be actively engaged in killing or attempting to kill in or at a DHHS facility. In most cases active shooters use a firearm(s) and display no pattern or method for selection of their victims. In some cases the assailant will use other weapons and/or improvised explosive devices to cause additional harm or to impede police and emergency responders.

DHHS Facility – Buildings and grounds operated and/or occupied by the North Carolina Department of Health and Human Services and its divisions, including the 14 state operated healthcare facilities.

Intimidation: Actions which lead to stalking or engaging in actions intended to frighten, coerce, or induce duress.

Physical Attack: Unwanted or hostile physical contact such as hitting, fighting, pushing, shoving, and throwing of objects or discharge of a firearm.

Property Damage: Intentional damage to property, which includes property owned by the state, staff, patients, visitors, or vendors.

Threat: The expression of intent to cause physical or mental distress or harm. An expression constitutes a threat without regard to weather the party communicating the threat has the present ability to carry it out and without regard to whether the expression is contingent, conditional, or future.

Violent Individual: A person who may cause serious bodily injury or death through the use of violence with or without a weapon.

Reporting and Responsibilities

It is the responsibility of each DHHS division/facility employee to be alert to the possibility of violence. An employee shall inform their supervisor or Human Resources if there is a domestic violence situation or any other situation in an employee’s personal life that has the potential to cause violence in the workplace. Employees shall report all acts of violence, threats of violence, and situations that may pose a threat to the safety of themselves and/or others. Employees acting in good faith who report threats or suspicious behavior will not be subject to retaliation or harassment based upon their report.

It is the responsibility of DHHS division/facility Human Resources departments to respond appropriately to reported threats and violence in accordance with the DHHS Workplace Violence Policy. All incident reports shall be confidential and released only as permitted by applicable law.

Implementation

All divisions/facilities/offices of DHHS are to implement policies and procedures to protect employees, patients, residents, visitors, and contractors in the event of a threatened or actual active shooter event on state property.

Each division/facilities/offices of DHHS will, at a minimum, adopt this plan or develop a written plan based on the assessment and recommendations of the Crisis Management Team or equivalent. For information about Crisis Management Team roles and responsibilities, refer to the DHHS Workplace Violence Policy.

Communication and Notification

Each DHHS division/facility/office must evaluate and document its communication systems and notification devices used to alert employees, patients, visitors and contractors, including intercom and public address systems, two-way radios, sirens, panic buttons, and other such devices. The division/facility must ensure that all systems are in working order and that all staff are aware of how to use such devices to alert staff and law enforcement in the event of an incident.

All DHHS divisions/facilities/offices must establish a communication system that can easily and rapidly inform staff of an Active Shooter event and remind staff to follow the RUN, HIDE, FIGHT procedures as outlined below.

The Crisis Management Team will evaluate communication systems to ensure that all areas of a building/campus are accessible to Active Shooter notifications and that all visitors and contractors are notified regardless of their whereabouts in the building or on the campus.

Each DHHS division/facility/office will establish multiple means of communication for notification of agency staff and local Law Enforcement.

All DHHS divisions/facilities/offices shall ensure that a “No Weapons Sign” is posted on all entrances into its facilities and that any No Weapons Signs posted have the North Carolina General Statutes 14-269.4 and 14-269 reflected in the posting.

Procedures

In the event of a threat of violence, employees who believe that a situation exists that may jeopardize the safety or security of a patient, employee, visitor or contractor on State property should immediately call 911 or contact their supervisor or manager. The employee should give a description of the person(s), and if possible describe the nature of the threat or give a description of any weapons if known (verbal abuse, knife or gun).

If an active shooter is believed to be near your area and you believe you can exit safely, you should follow these procedures to preserve life and property.

  1. Make an announcement to the entire affected area by some means of mass communication, such as a code announcement via an overhead public address system, email broadcast, telephone system, or intranet panic button.
  2. If possible, contact the local Police Department via 911 or other emergency number.
  3. Give as much information as you can to the dispatcher, including the following information to relay to the local Police Department.
    1. Number of shooters, if known
    2. Location of the shooter(s), if known
    3. Type of weapon(s) being used, if known

If an active shooter is in your area, remember to follow these steps to safely exit - RUN, HIDE, FIGHT.

  1. If you RUN, commit to getting away from the area as quickly and quietly as possible so as not to attract the attention of the shooter.
  2. Get away from the area completely. Don’t stop to look back!
  3. If it is possible, help others while you are escaping, but do not allow it to slow you down.
  4. If you cannot escape, find a place to HIDE or barricade. Follow facility lockdown procedures, as applicable.
  5. If you HIDE, turn off the lights, close the blinds, and silence cell phones, radios or other noise emitting devices so that you do not attract the attention of the shooter.
  6. If you must FIGHT, then commit to fighting for your life. Use anything that you can to disable, disarm or disorient the shooter, including chairs, books, fire extinguishers, phones, or improvised weapons.

Know what to expect from law enforcement officers when they arrive on the scene. Officers will be carrying weapons, and their primary task is to stop the shooter. They will likely be traveling in teams and will not be stopping to assist victims. The officers may not know the location or identity of the shooter, so do not let them mistake you for the shooter.

  1. If you encounter law enforcement officers, do exactly as you are told and remain as calm as possible under the circumstances.
  2. Empty and raise your hands and avoid rushing towards the officers.
  3. If an officer orders you to lay down on the ground, comply without objection, as they are trying to eliminate all suspects.
  4. Remain quiet and calm. Avoid shouting, pointing, screaming, or yelling.
  5. Don't stop and ask the officers for directions or evacuation points.
  6. If the officers keep moving, proceed in the direction from which they came until you are safely out of harm's way.

Staff/Patient/Resident Post Accounting

Each DHHS division/facility will establish a post-incident accounting system for all individuals on site, including but not limited to staff, patients, residents, vendors, and contractors who were on state property at the time of the drill or incident and report back to facility leadership regarding the status of the drill or incident. A debriefing is conducted with division/facility leadership to assess the incident and determine the need for procedures for continuity of operations, psychological assessment of affected individuals, and communication with families as applicable and in accordance with division/facility policies.

Active shooter incidents are documented using Attachment A. The completed form is kept on file by the designated division/facility Safety Officer or Safety Representative. A copy of the completed form is also sent to the DHHS Safety Programs Office.

Communication & Media Reports

Requests for information and media inquiries received by a DHHS division or office are to be directed to the DHHS Communications Office. All requests for information and media inquiries received by a DHHS facility are directed to the respective Division of State Operated Healthcare Facility leadership who will immediately refer such inquiries to the DHHS Communications Office. Facility security and/or local law enforcement can and shall be used to control access to the scene.

Support and Protection

It is recommended that each DHHS division/facility establish working relationships with the local law enforcement agencies that serve their area. Consultation with law enforcement can assist in the development of an effective emergency response plan and crisis management coordination.

Training

At a minimum, all DHHS staff view the RUN, HIDE, FIGHT video applicable to the specific type of facility in which they work. Employees working in administrative or office settings are assigned the Active Shooter Training Video for Office Workers. Employees working in a DHHS Facility are assigned the Active Shooter Training Video for Healthcare Facilities. Divisions/facilities may develop additional training courses as needed to address active shooter policies and procedures specific to that area.

Each DHHS division/facility must provide Active Shooter training that supports the RUN, HIDE, FIGHT response on an annual basis.

All training is to be documented with the names of employees in attendance and an attestation documenting that they attended and understood the information. Documentation of training is maintained in the employee’s training record.

All divisions/facilities/offices must complete an annual Active Shooter Drill. The drill coordinator records information about the drill and evaluates drill procedures using Attachment B. This documentation is maintained by the division/facility Safety Officer or Safety Representative.

Facility:

Building(s):

Location/Area(s):

Date:

Start Time:

End Time:

Names of Persons Involved:

Injured?

If yes, nature of injury:

 

Yes

No

 
 

Yes

No

 
 

Yes

No

 
 

Yes

No

 
 

Yes

No

 

Names of Witness:

   
   

Description of Event

 

Additional Questions:

Were procedures followed according to Active Shooter policy?

Yes

No

Was emergency response required?

Yes

No

________________________________________________________ ________________________________

(Site Director)--------------------------------------------------------------(DATE)

_________________________________________________ ___________________________

(Human Resources)-------------------------------------------------------(DATE)

__________________________________________________ ___________________________

(Safety Officer)-------------------------------------------------------------(DATE)

Facility:

Coordinator:

Building(s):

Location/Area(s):

Date:

Start Time:

End Time:

Drill Scenario:

Pre-Drill Planning:

Planning Process:

YES

NO

N/A

Were all key stakeholders involved in the planning process (i.e. law enforcement, fire officials, emergency management officials, etc.)?

     

Will you be drilling a specific scenario?

     

Has this drill been conducted this year?

     

Training:

YES

NO

N/A

Has the facility Active Shooter Plan been disseminated to ALL employees?

     

Have emergency duties been reviewed with ALL employees?

     

Has training been conducted with ALL employees?

     

Do staff members know procedures for handling staff/patients/residents with special needs?

     

Notification:

YES

NO

N/A

Has notification been sent out to ALL staff regarding the facility’s drill plan?

     

Were visitors on grounds notified prior to the drill?

     

Were emergency responders notified prior to drill?

     

Were staff members and/or contractors notified prior to drill?

     

Were emergency responders; eg. local law enforcement, fire and EMS etc. invited to attend the drill?

     

Comments:

 

During the Drill

Communication:

YES

NO

N/A

Were policy emergency codes utilized to notify announcements (i.e. lockdown, evacuation, etc.)?

     

Was the emergency announcement heard everywhere, including outside the building?

     

Do other staff have a means/method to communicate with the main office/ command post?

     

Was there an “All Clear” procedure to terminate the action?

     

General Procedures:

YES

NO

N/A

Were Patients/Residents and staff who were unable to evacuate secured behind locked doors?

     

If building occupants could not evacuate, did they hide completely out of sight?

     

Were staff following procedures and protocols according to the facilities emergency procedures?

     

Were procedures for staff in hallways, bathrooms and open areas being followed?

     

Were procedures for staff outside the building being followed?

     

Were staff doors locked in a timely manner?

     

Were all exterior doors locked?

     

Did all the building occupants participate in the drill?

     

Were lights turned off?

     

Were phones and electronic devices silenced?

     

Did staff open door or answer when someone knocked or tried to open the door? (If yes, explain)

     

Was a command post identified and used?

     

Comments:

 

Post Drill Follow-Up

Debrief:

YES

NO

N/A

Once completed, will staff supervisors debrief the drill with other staff?

     

Once completed, will administrators debrief the drill with staff?

     

Will the drill debrief include emergency responders?

     

Will after-action items be identified?

     

Comments:

____________________________________________________________ ________________________________

(Site Director)-------------------------------------------------------------- (DATE)

_________________________________________________ ___________________________

(Human Resources)-------------------------------------------------------(DATE)

__________________________________________________ ___________________________

(Safety Officer)-------------------------------------------------------------(DATE)

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