DA Emergency Management Plan

Emergency Management Plan Jeddah, Kingdom of Saudi Arabia December 2024.

Emergency Management Plan - Issue Date: 04 Nov. 2024, Effective Date: 04 Dec. 2024, Ver.1, Next Revision Date: 04 Dec. 2025 Page 2 of 20 Table of Contents I - Introduction 3 II - Definitions 3 III - Policy 4 IV - Scope 4 V - Mitigation 4 Identification of Hazards and Vulnerabilities 4 Hazards and Vulnerability Mitigation 5 VI - Preparedness 6 Committee / Teams Charges / Roles & Responsibilities 6 Contact Numbers – Internal & External 8 Coordination with Local Authorities and other Healthcare Facilities 8 Alternative Sources of Power & Water 9 VII - Training, Education, Communication & Drills 9 VIII - Response 10 Priorities 10 Alert, Warning, and Notification 10 Emergency Classification & Codes - following acronym (CHIEFS) 11 Teams 11 Emergency Response Resources 11 Internal Emergency Response 13 Response Activation: Internal Emergency (please see appendix A Response Flowchart) 13 Code Blue Policy, Crash Cart Policy, Forms (please see appendix B Response Flowchart) 15 Power Failure (please see appendix C Response Flowchart) 17 Water Interruption (please see appendix 4 Response Flowchart) 18 Code Pink - Child Missing/Abduction (please see Appendix E Response Flowchart) 19 Monitoring Compliance 21 Code White - Security Threat (Violence) [please see appendix F Response Flowchart] 22 External Emergency Response 24 Response Activation: External Emergency (please see appendix A Response Flowchart) 24 IX - Recovery 26 XI - Approvals 28.

mergency Management Plan - Issue Date: 04 Nov. 2024, Effective Date: 04 Dec. 2024, Ver.1, Next Revision Date: 04 Dec. 2025 Page 3 of 20 I. Introduction: Veneer Care Emergency Management Plan (EMP) was developed to establish a basic emergency preparedness program to provide a timely, integrated, and coordinated response to a wide range of natural and man-made disasters that may disrupt normal operations and require a pre-planned response. The reason for this approach is to: 1. Provide maximum safety and protection from injury for patients, their families, visitors, and staff. 2. Provide care promptly and efficiently to all persons requiring immediate medical attention in an emergency. 3. Provide a flexible chain of command to enable maximum use of resources. 4. Maintain and restore essential services immediately following an emergency or disaster. 5. Protect clinic property, facilities, and equipment. 6. Comply with regulatory and accreditation requirements. II. Definitions: Emergency is defined as a potential or actual destructive event, which, relative to the resources available, causes many casualties, usually occurring within a short period of time. The Emergency Management Center (EMC) is the control /communication center for all emergencies and is located in the clinic conference room. It is a specially designed and equipped room where designated members of management direct and control emergency response activities. Emergent Evacuation - Imminent circumstances making immediate evacuation essential (e.g., an uncontrolled fire, physical plant, or environmental emergency). Any delay in an evacuation is potentially life-threatening. All alternatives to evacuation have been considered and are not acceptable to Unified Command. Public safety resources (Civil Defense) may play a significant role in initial evacuation activities. Urgent Evacuation - Impending circumstances that potentially render the environment of care unsafe or inhospitable, or that may adversely impact the provision of patient care or ancillary services, where evacuation must commence within four hours to maintain a suitable environment to allow a unit/department to fulfill its mission (e.g., a physical plant, environmental, or mission- critical system problem that is not correctable within a short time frame). Alternatives to evacuation are being executed to obtain more time to effect an orderly evacuation process. Planned Evacuation - Circumstances are anticipated that require relocation of patient care or ancillary service activities within not less than 48 hours, or where ample time exists to inform patients and staff, plan activities, mobilize resources, and control the relocation without extraordinary measures (e.g., a planned alteration in physical plant, environmental, or staffing conditions). This type of evacuation normally will be anticipated several hours to days in advance and will not require extensive public safety resources. Time criteria will allow non-mutual aid ambulance resources to provide the required transport of patients between temporary locations or other facilities and the clinic..

Emergency Management Plan - Issue Date: 04 Nov. 2024, Effective Date: 04 Dec. 2024, Ver.1, Next Revision Date: 04 Dec. 2025 Page 4 of 20 Horizontal Evacuation – and evacuation from an area of danger to the nearest muster point (safe area) on the same floor. The Forward Control Team (FCT) in collaboration with the nurse manager/charge nurse is authorized to give the instructions for Horizontal Evacuation. Vertical Evacuation – and evacuation to the nearest muster point (safe area) on another floor (usually a lower level), or to a safe area outside the facility (usually a location in the facility grounds, although some patients may require removal to another facility). Vertical evacuation is only activated when there is a very serious confirmed threat to life and safety. The Medical Director or his designee is authorized to give the instructions for Vertical Evacuation. III. Policy: It is the intent to adequately prepare, mitigate, respond, and recover from a natural or man-made disaster or other emergencies for the safety of patients, visitors, and staff. The management appreciates all staff in their readiness to fulfill their duties and responsibilities as part of the team to provide the best possible care to patients especially in emergencies. Veneer Care will work in close coordination with the local emergency authorities to ensure a coordinated approach and response to disasters. The EMP is evaluated on an annual or on as needed basis whenever there are revisions in policies and procedures, structural and systems changes that will have an effect on the overall objective. The Quality Management in coordination with the Leadership Committee shall conduct the review and develop the recommendations to the Governance Committee for approval. IV. Scope: Within the context of the plan, a disaster is an emergency that exceeds or threatens to exceed the routine capabilities of the clinic. The plan encompasses the mitigation, preparation, response, and recovery from the effects of emergencies applicable to Veneer Dental Clinic locations, annexes, administrative areas and covers staff and contractors. The development and implementation of this plan are compliant with the relevant sections of the national and international standards and the local regulatory provisions. V. Mitigation: Veneer Dental Clinic implemented initiatives on assessment and hazard mitigation activities to be able to lessen the severity and impact of a potential emergency by identifying potential emergencies (or hazards) that may affect the clinic’s operations. Identification of Hazards and Vulnerabilities A multidisciplinary team is formed and charged to conduct an evaluation of organizational risks based on probability and impact of incidents against mitigation initiatives on an annual basis or at the call of the team whenever is required. Also, it will conduct an environmental safety survey in all its facilities at least on a quarterly basis to be able to rank problems and set priorities for remediation..

mergency Management Plan - Issue Date: 04 Nov. 2024, Effective Date: 04 Dec. 2024, Ver.1, Next Revision Date: 04 Dec. 2025 Page 5 of 20 Below is a tool adopted from Kaiser Permanente to conduct Hazard and Vulnerability Analysis (HVA). Hazards and Vulnerability Mitigation The process is the prevention of harm by data evaluation from the risks assessment and collected data. The following are examples of mitigation initiatives implemented at the clinic: a. environmental safety survey conducted on a scheduled basis b. policies and procedures development and on-going review as needed and/or upon expiry c. structural measures i. construction of protective works or alterations to meet or satisfy technical requirements ii. ongoing retrofitting and repairs per assessment and requirement d. non-structural measures – incorporate preventive aspects into budgets, preparation to provide medical attention during emergencies These initiatives can lower and diminish the level of risks and cost-effective in a way that before an emergency occurs, much more can be saved in terms of losses prevented. VI. Preparedness: Part of the readiness initiative is the formation and identification of the following: Committee / Teams Charges / Roles & Responsibilities SN Committee / Team Charges 1. Emergency Preparedness discussed in leadership Committee Responsible for developing and maintaining a plan, policies, and procedures for a coordinated response to promote the safety of patients, their families, staff, property maintenance, and business continuation. 2. The leader is reviewed on an annual basis or as the need arises depending on the changes in standards, clinic structure, and staffing needs..

Emergency Management Plan - Issue Date: 04 Nov. 2024, Effective Date: 04 Dec. 2024, Ver.1, Next Revision Date: 04 Dec. 2025 Page 6 of 20 SN Committee / Team Charges 3. Leader is ensured to be distributed to all departments/services by the delegated department/personnel. 4. leader is in constant coordination with the FMS Team. 5. Oversight of the department’s obligation to keep their staff updated, aware, and follow their respective roles and responsibilities during an emergency. 6. Develop and update agreements with other community health care providers and with civil authorities. 7. Emergency Management Center (EMC) Lead and direct the overall facility mobilization and response to an emergency. 8. Bears the responsibility to ensure that the entire response is carried out in an effective, efficient and, coordinated manner 9. Overall direction for Clinic Director during an emergency and if needed, authorize evacuation 10. Forward Control Team (FCT) Activated upon or simultaneously with the EMC per announced emergency code 11. Concerned FCTs upon direction by the EMC, shall proceed to the announced location where an emergency occurs to assess, control, take appropriate measures, and report status to EMC for information and/or further advice SN Committees / Team Members Members Roles/Responsibilities Emergency Management Center (EMC) 1. Emergency Command Center Leader a. Provide overall direction to the team if needed, authorize evacuation b. Record incident-related problems c. Record any other documentation necessary as directed by EMC Leader 2. Clinic Director a. Organize and direct operations to maintain the physical environment b. Maintain adequate levels of food, shelter, and supplies supporting the medical objective 3. Nursing Supervisor / Head a. Organize and coordinate nursing activities. b. Direct patient care services 4. Clinic Director (FMS) a. Contact and coordinate physicians. b. Assist in assigning available medical staff. 5. FMS\Third party CO. FMS\Third party Co. a. Protect, evaluate, control, repair, and maintain plant and utility systems necessary for patient care in support of the disaster condition. b. Implement back-up measures in the event of utility failures. c. Assign Unit Leaders for power, water, HVAC, electric ..

mergency Management Plan - Issue Date: 04 Nov. 2024, Effective Date: 04 Dec. 2024, Ver.1, Next Revision Date: 04 Dec. 2025 Page 7 of 20 6. (FMS) leader a. Appoint teams and develop procedures for the following response tasks: i. Light search and rescue - appoint and train a light search and rescue team to ensure all rooms are empty and all staff, patients, and visitors leave the premises when the clinic is evacuated. ii. Appoint and train a damage assessment team on each shift to evaluate the damage SN Forward Control Teams Composition Objectives / Charge 1. Code Red – Fire i. Clinic Director ii. FMS Leader iii. Nursing Supervisor iv. Admin manager Effective collaboration between departments/services and personnel during fire emergencies and to meet the national & international standards, related national regulations, and the provision of proper education and training to staff and contractors in the fire prevention and emergency response. 2. Code White – Security Threat / i. Clinic Director (Leader) ii. Admin manager iii. Nursing Supervisor Violence A high-level response to actual or potentially violent, aggressive, threatening behavior, by the patients, visitors, and/or staff, towards others or themselves, which creates a risk to health and safety. 3. Code Orange – Hazardous Materials Spill i. Infection Control (Leader) ii. Clinic Director iii. Nursing Supervisor iv. Fms leader v. Housekeeper supervisor Implementation of developed measures highly essential for safe and environmentally sound management of wastes preventing adverse health and environmental impact. 4. Code Pink – Child Missing / Abduction i. Clinic Director (Leader) ii. Patient Relations Supervisor iii. Nursing Supervisor To facilitate a speedy recovery of a child that is missing and/or may have been abducted, this code being activated entails immediate mobilization of protocols. 5. Code Blue – Cardiac Arrest i. Physician (Leader) ii. Nurse Activated for resuscitation response management in the event of a cardiopulmonary arrest situation in all clinic areas and non-clinical areas. 6. Code Yellow – External i. Clinic Director ii. FMS leader Disaster (External) All teams/departments/services and/or upon the discretion of the EMC to activate and coordinate immediately for external disasters. call 911 to coordinate with Red Crescent 7. MOH Disaster & Emergency Codes Attached as immediate reference for all other codes.

Emergency Management Plan - Issue Date: 04 Nov. 2024, Effective Date: 04 Dec. 2024, Ver.1, Next Revision Date: 04 Dec. 2025 Page 8 of 20 Contact Numbers – Internal & External Name Job Title Tel. No. | Mobile No. Veneer Care Dr. Ali Mohammed Aftanh Clinic Director +966 505565560 Ms.Samirah Bahkali FMS Leader +966 570630718 Dr. Mashael Khalid Matar Medical Director/ Quality Coordinator +966565394142 Ms.Denalyn Galudo Dental Assistant/Nurse Supervisor +966 553817491 Ms.Wafaa Mohammed Alshawush Admin Manager/ HR/ Patient relation +966504879703 Ministry of Health (MOH) - Jeddah Emergency Office 0122327545 Civil Defense 998 Police Department - Jeddah Police 911 Coordination with Local Authorities and other Healthcare Facilities Veneer Care has entered into a memorandum of understanding with other primary healthcare centers in the event of medical emergencies beyond the clinic’s capacity and resources. Also, there will be coordination with the local agencies like the Regional Emergency Preparedness under the Civil Defense, Ministry of Health, Ministry of Defense, and the other private hospitals. The Civil Defense Presidency controls the scene in case of disaster where the Ministry of Health controls the operational center to control the medical flow and supplies. Alternative Sources of Power & Water Power Failure Veneer Care is not an emergency clinic, and in the event of a power failure, all patients are contacted and their appointments are scheduled at appropriate times. There is no procedure in the clinic that is considered an emergency. Any action taken by the doctor may stop the treatment and another appointment will be scheduled for the patient, and in the case of surgical operations. We communicate with a third party agreement with Nayel Clinic transfer the patient and complete treatment. For Medication refrigerator on UPS, also sent to Nyel clinic with agreement. Contact Electrical Co. Then we turn off all devices connected to the electrical current. Water Interruption There are many causes of water supply interruptions that impact the quality of care, patient safety, and facility operations, such as natural disasters, failure of the community water system, construction damages, and even acts of terrorism..

mergency Management Plan - Issue Date: 04 Nov. 2024, Effective Date: 04 Dec. 2024, Ver.1, Next Revision Date: 04 Dec. 2025 Page 9 of 20 Veneer Care ensures that, if not adequate, continued water supply is present in cases of emergencies until the system is back to normal. The following measures are in place: 1. Maintenance of the water reservoir and ensure that it is full most of the time. 2. Water testing and quality control 3. There is a number to contact White Water in case of emergency Mobile Number. VII. Training, Education, Communication & Drills: Veneer Care has incorporated the disaster preparedness information into its normal communications and education programs for staff: 1. Information on Veneer Dental Clinic emergency preparedness activities and staff responsibilities. 2. Procedures for emergency evacuation, including alarm systems, exit routes, and meeting areas. 3. Responsibilities for predetermined staff to perform critical duties prior to evacuation 4. Rescue and medical duties for those employees who are to perform them. 5. Information dissemination channels for these activities include newsletters, pamphlets, health education and in-service education classes, internet postings, and specific personnel who can be contacted with questions. Drills are conducted and documented on regular basis for all departments/services spearheaded or under the direction of the EMC. The evaluation and/or revision of drills depend on the actual emergency data analysis, trends, and recommendations. VIII. Response: Time is of essence for a response to an emergency or disaster in a healthcare setting that prevents fatalities, injuries, reduces damage to properties and/or equipment, protects the environment and community, and will accelerate the resumption of normal operations. Priorities 1. Life safety: provide for the safety of patients, staff, and visitors 2. Contain hazards that could pose a threat to people in the facility 3. Provide care for injured patients, staff, and visitors 4. Protect critical infrastructure, facilities, vital records, and other data 5. Resume the normal delivery of Dental care Alert, Warning, and Notification The following are mobilized upon switchboard/telephone operator receipt of information from credible sources: 1. The Emergency Management Center (EMC) is activated and informed. 2. It follows with the Forward Control Team (FCT) activation based on the code of the emergency announced. 3. FCT proceeds to the given location for immediate assessment and review of plans and considers possible actions immediately. 4. Depending upon the potential impact of the emergency, the EMC upon the FCT.

Emergency Management Plan - Issue Date: 04 Nov. 2024, Effective Date: 04 Dec. 2024, Ver.1, Next Revision Date: 04 Dec. 2025 Page 10 of 20 recommendation might decide to: ▪ Evacuate the facility ▪ Suspend dental operations ▪ Essential equipment secured, computer files back-up, and essential records stored off- site ▪ Implement measures to reduce clinic, staff, and patient risk ▪ Notify and communicate status to local authorities & health agencies Veneer Dental Clinic staff who observes an incident or condition which could result in an emergency condition should report it immediately to his/her supervisor and upon initial verification, shall call switchboard/telephone operator to proceed with the appropriate protocol and code activation. the code 6300. Emergency Classification & Codes based on MOH approved Codes: Emergency Code Classification Cardio-Pulmonary Resuscitation Code Blue Cardiopulmonary arrest or imminent arrest Hazardous Material Code Orange Hazardous material spill/ release Internal Disaster Code Brown (Utility Failure) Internal emergencies need committees’ decision & action: ▪ Power outage ▪ Information technology disruption ▪ Utility disruption Code Black Bomb threat or suspicious item (mail, message) Code Red Fire, Internal Emergency / Disaster Security Code White Combative person, Assault / Abusive Behavior, Violent Situation (with no weapon) Code Pink A child / infant is missing or known to have been kidnapped. Code Silver Active shooter with weapon, hostage situation) Teams: (please refer to chapter VI Preparedness for its charges, roles and responsibilities) ▪ Emergency Management Center ▪ Forward Control Teams Emergency Response Resources SN Resources / Actions Details.

mergency Management Plan - Issue Date: 04 Nov. 2024, Effective Date: 04 Dec. 2024, Ver.1, Next Revision Date: 04 Dec. 2025 Page 11 of 20 1. Staffing Veneer Dental Clinic primarily relies on its staff for emergency responses and used the following basic measures in the evaluation of staff capability and availability through the identification of: a. clinical staff with conflicting practice commitments b. clinical staff and support staff c. staff with distance and barriers limiting their ability to report to the clinic d. a staff that can respond rapidly to the clinic. e. bi-lingual staff by language 2. Medical Equipment Department/services determines the following in so far as supplies are concerned: a. the level of supplies possible to put in stock in the clinic b. storing only those that are highly likely to be needed immediately in a response or its day-to-day operations 3. Communications Utilize available communication resources for internal coordination, external emergency response agencies, and the local authorities 4. Security a. All Veneer Dental Clinic staff, contractors, and suppliers are required to wear ID badges at all times. b. Ensure that the clinic site is and remains secure following an evacuation 5. Damage Assessment FMS leader assess the damage caused by the disaster to determine if an area, room, or building can continue to operate safely or safe to reenter following an evacuation 6. Hazardous Materials Management Refer to the Hazardous Materials and Waste Management Program 7. Evacuation Procedures Veneer Dental Clinic may be evacuated due to a fire or other occurrence, threat, or upon order of the Clinic Director. Protocols are activated in shutting-off the utilities, including emergency equipment, gas, electrical timers, water, computers, heating, AC, compressor, and telephones 8. Decision on Clinic Operational Status Following the occurrence of an internal or external disaster or the receipt of a credible warning, the Clinic Director will decide the operating status for the clinic in which the decision is based on the results of the damage assessment, the nature, and severity of the disaster, and other information supplied by emergency responders. SN Resources / Actions Details.

Emergency Management Plan - Issue Date: 04 Nov. 2024, Effective Date: 04 Dec. 2024, Ver.1, Next Revision Date: 04 Dec. 2025 Page 12 of 20 The decision to evacuate Veneer Dental Clinic, return to the facility, and/or re-open the facility for partial or full operation depends on an assessment of the following: a. Staff availability b. The extent of facility damage / operational status c. Status of utilities (e.g. water, and electricity) d. Presence and status of hazardous materials e. Condition of equipment and other resources f. Availability of supplies g. Environmental hazards near the clinic h. Recommendation of local authorities i. Extended Clinic Closure If there is major damage, loss of staffing, a dangerous response environment, or other problems that severely limit the clinic’s ability to meet patient needs, the EMC Leader in consultation with the General manager may suspend clinic operations until conditions progress. Internal Emergency Response An internal emergency as defined is an event that may disrupt operations, jeopardize the safety and well- being of the occupants of the facility, or significantly cause damage to it. Goals: a. Establish procedures to be followed in the event of an internal emergency within Veneer Dental Clinic. b. Provide guidance in safe work habits and education to personnel through detailed instructions (example action plans, fire and safety plan, unit drills, etc.) c. Protect patients, visitors, staff, and contractors and to minimize property damage d. Practice an orderly evacuation procedure if evacuation becomes necessary. Response Activation: Internal Emergency (please see appendix A Response Flowchart) SN Action / Situation Details Responsible Person Timeframe a. Switchboard / Tel Operator (Hotline Nos. 6300 ) Received a call/ notice Received a call of an emergency using the following codes: Code Red – Fire Code White - Security Threat / Code Pink - Child Missing / Abduction Code Orange - Hazardous Materials Spill Code Blue - Cardiopulmonary Arrest Switchboard / Tel Operator Immediate b. Emergency Confirmed? If emergency is confirmed and identified, proceed to section g., else, proceed to next section c. Switchboard / Tel Operator Immediate c. Switchboard 6300 / Tel? Operator to Call Call or page the FMS Manager and the Clinic Director to proceed to the reported emergency location FMS leader Clinic Director Immediate after receipt of call.

mergency Management Plan - Issue Date: 04 Nov. 2024, Effective Date: 04 Dec. 2024, Ver.1, Next Revision Date: 04 Dec. 2025 Page 13 of 20 d. Assessment Upon reaching the site, coordinate with the Area Manager/Supervisor on the reported emergency and conduct an assessment of the situation FMS leader Clinic Director As soon as reaching the area e. Report to EMC After conducting the initial assessment, report to the Emergency Management Center (EMC) for information and action as well as the category or type of emergency either internal or external FMS leader Clinic Director After data/ information gathering f. Forward Control Team (FCT) Activation The EMC upon receipt of the report with initial and verified information on the emergency is activating the FCT in accordance with the emergency code and type EMC FCT After receipt of the report g. Internal Emergency Switchboard/Tel Operator as advised by EMC announced through the public address system the code “Code + location” 3x EMC As soon as notified h. FCT to Proceed to Area FCT upon activation proceeds to the emergency site and conduct the standard assessment procedures or the required protocols to suppress or control the situation FCT Immediate after arrival i. Situation Controlled The application of protocols or remedies has controlled the situation FCT - j. Report Status to EMC FCT to report the status to EMC thereby confirming that the emergency has been controlled and the area is safe. Also, to coordinate with the Area Manager/Supervisor about the status and that the area is safe for work EMC FCT Immediate after the incident is controlled k. Announcement Switchboard/ Tel Operator upon advised or call received from EMC shall announce “ Code + Location All Clear” 3x EMC Switchboard/ Tel Operator Upon receipt of call/notice l. Situation Not Controlled If the situation has aggravated and not controlled, FCT implements further measures including the participation of additional experts to be able to control the emergency the soonest as possible FCT Immediate & Ongoing m. Go to section H. through K. - Code Blue Policy Cardiopulmonary arrest at any given time occurs in and outside the premises of healthcare facilities. The resuscitation service, activation, response and management are detailed below. SN Action / Situation Details Responsible Person Timeframe.

Emergency Management Plan - Issue Date: 04 Nov. 2024, Effective Date: 04 Dec. 2024, Ver.1, Next Revision Date: 04 Dec. 2025 Page 14 of 20 a. A person having a Cardio- pulmonary Arrest Veneer Dental clinic staff identified a patient, a family, or a visitor suspected of having a cardiopulmonary arrest inside the facility Staff - Immediate b. Assessment Staff conduct rapid assessment Staff - Immediate Non -clinical Area c. Call Switchboard 6300/ Tel Operator Staff to call switchboard /Tel. Operator at ext. 6300 activate code blue or delegate it to someone: ▪ clearly state Adult or Pediatric Code Blue ▪ identify the specific location ▪ room number if applicable Staff Immediate d. Switchboard 6300/ Tel Operator Announceme nt Switchboard / Tel Operator to announce: 3x ▪ “(Adult/Peds) Code Blue + Location” ▪ “(Adult/Peds) Code Blue + Location” ▪ “(Adult/Peds) Code Blue + Location” Switchboard / Tel Operator After receipt of confirmation e. Rapid Assessment & Response Initial responder conducts rapid assessment & response ▪ Call for assistance ▪ Identify the area – clinical ▪ Ensure the patient/person is lying straight flat ▪ Check pulse (carotid pulse) ▪ Perform Cardiopulmonary Resuscitation (CPR) / start compression Staff Immediate f. CPR Second responder (Nurse) ▪ Start BLS ▪ secure backboard under the patient/person if present ▪ Bring AED ▪ Switch role with the first responder in giving chest compressions to the patient/person ▪ Call Contractor hospital ▪ Send the patient to contractor Hospital Staff Upon code activation Clinical Area g. Call Switchboard / Tel Operator Staff to call switchboard /Tel. Operator at ext. _6300_to activate code blue or delegate it to someone: ▪ clearly state Adult or Pediatric Code Blue ▪ identify the specific location ▪ room number if applicable Staff Immediate.

mergency Management Plan - Issue Date: 04 Nov. 2024, Effective Date: 04 Dec. 2024, Ver.1, Next Revision Date: 04 Dec. 2025 Page 15 of 20 h. Switchboard / Tel Operator Announceme nt Switchboard / Tel Operator to announce: 3x ▪ “(Adult/Peds) Code Blue + Location” ▪ “(Adult/Peds) Code Blue + Location” ▪ “(Adult/Peds) Code Blue + Location” Switchboard / Tel Operator After receipt of confirmation i. - Unit Code Blue Team sufficient to mobilize go to sections G. through M. Unit CBT immediate j. - Unit Code Blue Team not sufficient to mobilize go to sections B. through M. CBT immediate Code Pink, Listed below is the response process in the event and/or upon discovering that a child is missing or may have been abducted. SN Action / Situation Details Responsible Person Timeframe a. Missing Child staff received information from the family that their child is missing in the vicinity and nowhere to be found Staff - b. Inform Supervisor Upon knowing this unexplained absence of the child, the staff inform his/her supervisor of the concern Staff after receipt of the information c. Search The Supervisor deploys more staff to conduct an immediate search of the area (careful not to remove or disturb anything which might be useful for future evidence or may cause alarm to other patients/families in the vicinity) Supervisor / Staff Upon Instruction d. Inform Tel Operator While the search is in progress, the supervisor or person-in-charge calls the Tel Operator stating “Child missing; possible abduction”, age & last sighting are communicated Supervisor Same time the search is in progress e. Announcement Tel Operator to announce “Code Pink + Location” 3x Tel Operator After Receipt of Call f. Team Activation Upon the announcement, Emergency Management Center (EMC) and Forward Control Teams (FCT) are activated EMC FCT Immediate g. FCT on Site Upon its activation, the FCT proceed to the announced location and conduct an initial assessment FCT Upon Arrival on Site h. Child is Located After FCTs assessment/search in the area and nearby vicinity, the child has been found and coordinated with staff and family FCT Immediate.

Emergency Management Plan - Issue Date: 04 Nov. 2024, Effective Date: 04 Dec. 2024, Ver.1, Next Revision Date: 04 Dec. 2025 Page 16 of 20 i. Report to EMC FCT is to report progress/status to EMC of the situation and inform Tel Operator of “Missing Child Found” after locating the child and coordinating with family and staff FCT After coordinating with family j. Announcement To announce “Missing Child Found, All Clear” 3x Tel Operator After Receipt of Call k. Child Not Located From section G., after a thorough search by FCT, the child is still missing or nowhere to be found, family and staff updated FCT Immediate l. Notification – Local Police FCT provides a status report to EMC and EMC notifies local authorities EMC FCT Immediate m. Local Police Arrival at site Local authorities arrived at the site, assume full control and authority over the scene, conduct investigation and management of the child recovery Local Police Immediate after arrival n. Scene Investigation The crime scene is secured to preserve forensic evidence Local Police Immediate o. Facility Lockdown Immediately, as part of the investigation, a full building lockdown is directed therefore, security personnel and other staff are deployed at all access and car park to prevent people’s movement, however, this move should be discreet and will only state if queried that “there is a potential security breach” FMS leader Immediate Upon Instruction p. Family in Holding Room The family is brought to a private room with an assigned clinic staff Staff Immediate q. Facility Search Facility-wide search conducted Local Police ongoing r. Child Not Located After a full facility search and still, if the child is missing or could not be found, FCTs will update EMC and the local police to conduct further investigation until resolved. The clinic’s case is still open pending a police update and/or the child’s recovery Local Police Immediate after a full search s. Child is Located If the child is found after a full facility search, he/she is handed over to the family in the presence of senior staff, in coordination with local police for necessary documentation FCT Local Police Immediate after the search t. Report to EMC FCT reports progress/status to EMC and EMC informs telephone Operator of “Missing Child Found” FCT After coordination with family u. Announcement To announce “Missing Child Found, All Clear” 3x Tel Operator After Receipt of Call.

mergency Management Plan - Issue Date: 04 Nov. 2024, Effective Date: 04 Dec. 2024, Ver.1, Next Revision Date: 04 Dec. 2025 Page 17 of 20 v. Post Internal Activities EMC & FCTs to initiate in coordination with respective Managers the following: 1. Staff – conduct necessary post-traumatic stress debriefing as soon as possible 2. FCT team to convene, debrief and confirm seriously of the event & determine the investigation level appropriate applied 3. Clinic Administration to re-ensure the applicability of full security measures to avert such incidents in the future Clinic Admin EMC FCT Senior Managers Immediate Post Incident Monitoring Compliance 1. Day-to-day function of security matters, strategic overview, and specific site-related matters are under the responsibility of FMS leader 2. Compliance with the stipulated protocol is monitored as part of the serious incident investigation and any concern shall be included in the action plan to be developed as part of the process. Code White - Security Threat (Violence) This is the response process and management of a situation involving an aggressive, hostile, combative, or potentially combative person(s) occurring within the premises of the clinic. This applies to all staff directly involved in physical abuse or psychological harm with patients, their relatives, visitors, and other staff. SN Action / Situation Details Responsible Person Timeframe a. Combative Situation Identified/ Witnessed Staff confronted and/or witness confrontational situation will report and/or call the telephone Operator and provide full details Staff Immediate b. Announcement Tel Operator to announce “Code White Violence + location” 3x Tel Operator Upon receipt of call & clarification c. EMC & FCT Activation EMC & FCT upon announcement are activated EMC FCT Immediate d. Situation Control FCT proceed to location and control the situation FCT Upon arrival at the site e. Investigate An initial investigation is conducted to determine and identify the issue, assailant & victim FCT Immediate f. Further Investigation All involved persons are brought to FMS leader for further investigation FMS leader Immediate g. Report report to the Management the details with case severity (major or minor) FMS leader After Investigation External Emergency Response An external emergency is an event occurring outside Veneer Care perimeter that produces victims in numbers, and types of injuries, that threaten to overwhelm the clinic’s response capacity..

Emergency Management Plan - Issue Date: 04 Nov. 2024, Effective Date: 04 Dec. 2024, Ver.1, Next Revision Date: 04 Dec. 2025 Page 18 of 20 Goals: a. Establish procedures to respond to any external emergency. b. Facilitate evacuation of patients should an internal emergency escalate and be activated into an external emergency. c. Facilitate a fully integrated multidisciplinary approach in the event of an external emergency. d. To guide clinic staff through detailed instructions, to increase confidence, and to effectively treat/assist patients. e. To ensure the safety and security of patients, visitors, contractors, and staff. f. To be an active participant in regional planning and cross-jurisdictional actions between agencies to mitigate emergencies. IX. Recovery: Accounting for Disaster-Related Expenses The Finance Department will account for disaster-related expenses. The documentation are as follows: 1. Direct operating cost 2. Costs from increased use 3. All damaged or destroyed equipment 4. Replacement of capital equipment 5. Construction-related expenses 6. Return to normal clinic operations as rapidly as possible Inventory Damage & Loss Documentation of damages and losses of equipment against the current inventory with details such as serial numbers, costs, and date of the inventory. Copies are kept in the Finance Department. Lost Revenue through Disruption of Services All expenses will be documented incurred during the emergency or disaster. An audit trail will be developed to assist with qualifying for any reimbursement or assistance available for costs and losses incurred by the clinic. Cost/Loss Recovery Sources Reimbursement for response costs and losses shall be completed and submitted to the management for further processing. Restoration of Services The management will take the following steps to restore services as soon as possible: 1. If necessary, repair Veneer Dental Clinic facility or relocate services to a new or temporary facility. 2. Replace or repair damaged medical equipment. 3. Expedite structurally and licensing inspections required to re-open. 4. Facilitate the return of medical care and other clinic staff to work..

mergency Management Plan - Issue Date: 04 Nov. 2024, Effective Date: 04 Dec. 2024, Ver.1, Next Revision Date: 04 Dec. 2025 Page 19 of 20 5. Replenish expended supplies and pharmaceuticals. 6. Decontaminate equipment and facilities. 7. Attend to the psychological needs of staff. 8. Follow-up on rescheduled appointments. After Action Report (AAR) Veneer Dental Clinic will be conducting an after-action debriefing (interactive) with the departmental/service staff. This will also produce an after-action report describing the activities and the corresponding corrective action plans including recommendations to modify the capacity expansion procedures, additional training, and improved coordination as deemed necessary. The objectives of this activity are as follows: 1. Identify the lessons to be developed practical and actionable steps to improve existing systems 2. Identify the areas that may benefit from added technical assistance or to refine capacity- building efforts to address real-life challenges 3. Disseminate and share lessons learned from the review with all staff 4. Provide documented evidence to support the aim for resource mobilization X. Approvals: Prepared by: Name & Sign : Ms. Samirah Abdullah Bahkali Position : FMS Leader Date : 04 Nov 2024 Reviewed by: Name & Sign : Dr. Mashael Khalid Matar Name & Sign : NP. Denalyn Agoylo Galudo Position : Quality Coordinator/Medical Director Position : Head Nurse Date : 07 Nov 2024 Date : 11 Nov 2024 Name & Sign : Ms Wafaa Mohammed Alshawush.

Emergency Management Plan - Issue Date: 04 Nov. 2024, Effective Date: 04 Dec. 2024, Ver.1, Next Revision Date: 04 Dec. 2025 Page 20 of 20 Position : Admin Supervisor Date : 13 November 2024 Approved by: Name & Sign : Dr. Ali Mohammed Aftan Position : Clinic Director Date : 14 Nov. 2024.