Preparedness

The Pacific Northwest is vulnerable to multiple threats and hazards.  These include natural hazards such as earthquakes; severe weather, including wind, rain and occasionally snow storms; floods; landslides; fires; and volcanic eruptions.  Additionally, there are man-made hazards such as hazardous materials spills and potential civil unrest and/or terrorism.

While each of these threats is a problem in and of themselves, they are frequently the cause of secondary issues such as long-term power and telephone outages.  In some cases, the event may cause disruption to critical supplies and services such as food, medical supplies and gasoline.

PreparednessPreparedness Template

Preparing for such disasters is critical for ensuring the safety and security of residents, staff and visitors of long-term care facilities.

I.      PURPOSE

To provide guidance to                                                  (facility name) on emergency policies and procedures to protect the lives and property of residents, staff and visitors.

II.     SITUATION AND ASSUMPTIONS

A.   AUTHORITIES

  1. WAC 388-76-670:  Aging and Adult Services / Adult Family Homes; Disaster and emergency preparedness.
  2. WAC 388-97-315: Nursing Homes; Emergency power.
  3. WAC 388-78A-2700: Boarding Homes; Safety measures and disaster preparedness

B.   Situation

  1. The Pacific Northwest region is vulnerable to both natural and man-made disasters.
  2. Residents of this facility require special emergency considerations in planning for disasters or emergencies and in ensuring safety.

C.   Assumptions

  1. The possibility exists that an emergency or disaster may occur at any time.
  2. In the event an emergency exceeds the facility’s capability, external services and resources may be required.
  3. Local, state and federal departments and agencies may provide assistance necessary to protect lives and property.
  4. Depending on the scope of the event and the type of assistance needed, local, state and federal departments and agencies may be unable to respond immediately.  It is the responsibility of the care facility to be prepared to care for the residents, staff and visitors for seven to ten days.
  5. The care facility will comply with all state and local requirements for review and inspection of safety plans and procedures.

III.     CONCEPT OF OPERATIONS

The care facility should have an emergency action plan in place capable of providing for the safety and protection of residents, staff and visitors.  Procedures should be developed to insure that residents who are cognitively impaired, physically impaired, hearing impaired, speech impaired, or have English as a second language are properly informed and alerted as necessary.

This plan can be effective for either internal or external emergencies.

A.   Pre-Emergency

  1. Evaluate the facility’s potential vulnerabilities.  (See Attachment A.)
  2. Review, exercise and re-evaluate existing plans, policies and procedures.
  3. Develop Mutual Aid Agreements with similar types of facilities, both in and outside the immediate area.  Review and update the Agreements regularly.  (Maintain a copy of all Agreements as Attachment D.)
  4. Review and update inventory/resource lists.
  5. Determine communication systems.  (E.g., cellular phones and fax machines may offer the best means in the event of a power loss.  A supply of quarters and accessibility to a pay phone may serve as a reasonable alternative.)
  6. Ensure the availability and functioning of facility emergency warning system / public announcement system.
  7. Test reliability of emergency telephone roster for contacting personnel and activating emergency procedures.  (See Attachment C.)
  8. Install and maintain emergency generators.
  9. Identify power needs based on which equipment and appliances are necessary for the safety and security of residents, staff and visitors.
  10. Have a licensed electrician install the generator.
  11. Develop procedures for testing generators and equipment supported by emergency generators.
  12. Maintain a 7 to 10 day supply of emergency fuel.  Establish a delivery agreement with a supplier.
  13. Activate and test the generator under load according to National Fire Protection Association (NFPA) requirements and state and local regulations.
  14. Document all testing procedures.
  15. Ensure a 7 to 10 day supply of food and water for residents and staff.  (Have at least one gallon of water, per person, per day on hand.)
  16. Arrange for a private contact to supply back-up resources.
  17. Rotate supplies and check expiration dates regularly.
  18. Schedule employee orientation training and in-service training programs on the operations of the emergency plan.
  19. Enhance emergency education.
  20. Distribute preparedness checklists provided in Attachment B.
  21. In accordance with state and local codes and requirements:  Post display of evacuation routes; alarm and fire extinguisher locations; and emergency contact telephone numbers.
  22. Provide demonstrations on warning systems and proper use of emergency equipment for the staff, residents, and residents’ families.
  23. Encourage personal preparedness for all staff.
  24. Conduct fire drills at a minimum of once per quarter per shift.  (Check fire regulations in your community for local, federal and state compliance requirements.)
  25. One drill is required per quarter for each shift at varied times.
  26. Document each drill, instruction or event to include date, content and participants involved.
    1. Identify and document any problems associated with the drill.
    2. Develop and implement an improvement plan for problems associated with the drill.
  27. It is recommended that at least one drill be conducted on an annual basis to exercise all aspects of the emergency action plan.  Document drills with critiques and evaluations.
  28. Develop and maintain Standard Operating Procedures (as Attachment C to this document) to include:
  29. Task assignments (by title, not individual names)
  30.  Security procedures
  31. Personnel call down lists
  32. Emergency supplies; storage, maintenance and use
  33. (location) is the designated Command Post (CP) and will serve as the focal point for coordinating operations.  If evacuation is necessary, the alternate location will be  (location).
  34. Ensure all staff are trained on the disaster plan to execute the activities of the Command Post.  All staff should know the location of the Disaster Preparedness Plan.
  35. Plan for evacuation and relocation of residents.
  36. Identify the individual responsible for implementing facility evacuation procedures.
  37. Determine the number of ambulatory and non-ambulatory residents.  Identify residents who may need more than minimal assistance to safety evacuate (including Hospice) and ensure staff are familiar with individual evacuation plans for those residents.
  38. Identify and describe transportation arrangements made through Mutual Aid Agreements of Memoranda of Understanding that will be used to evacuate residents.  (Attach copies of documents to this plan as Annexes.)
  39. Describe transportation arrangements for logistical support to include moving and protecting records, medications, food, water and other necessities.
  40. Identify facilities and include in the plan a copy of the Mutual Aid Agreement or Memorandum of Understanding that has been entered into with a facility to receive residents.  (Attach copies of documents to this plan as Annexes.)
  41. Identify evacuation routes that will be used as well as secondary routes should the primary routes be impassable.
  42. Determine and specify the amount of time it will take to successfully evacuate all patients to the receiving facility.
  43. Specify the procedures that ensure facility staff will accompany evacuating residents and procedures for staff to care for residents after evacuation.
  44. Identify procedures to keep track of residents once they have been evacuated.  Include a log system.
  45. Determine what items and how much each resident should take.
  46. Plan for evacuation and shelter of pets and service animals.
  47. Establish procedures for responding to family inquiries about residents who have been evacuated.
  48. Establish procedures to ensure all residents and staff are out of the facility and accounted.
  49. Determine when to begin pre-positioning of necessary medical supplies and provisions.
  50. Specify at what point Mutual Aid Agreements for transportation and the notification of alterative facilities will begin.
  51. Identify contact information for community resources available to provide emergency services during a disaster.  These may include: volunteers, churches, clubs and organizations, emergency medical services, law enforcement, fire departments, businesses, hospitals, and local government departments and agencies.
  52. Establish a plan for donations management.  Delineate what is needed; where items will be received and stored; and who will manage donation management operations.

B.   Preparedness

Upon receipt of an internal or external warning of an emergency, the facility Administrator or appropriate designee(s) should:

  1. Notify staff in charge of emergency operations to initiate the disaster plan.  Use Notification Check List or Emergency Call Down Roster.  Advise personnel of efforts designed to guarantee resident and staff safety.
  2. If potential disaster is weather related, closely monitor weather conditions and update department directors as necessary.
  3. Inform key agencies of any developing situation and protective actions contemplated.
  4. Review Disaster Preparedness Plan, including evacuation routes, with staff and residents.
  5. Prepare the                                                     (location) for Command Post operations and alert staff of impending operations.
  6. Contact residents’ families.  Coordinate dissemination of messages.
  7. Control facility access.
  8. Confirm emergency staff availability.  Facilitate care of their families.
  9. Pre-arrange emergency transportation of non-ambulatory residents (dialysis residents, etc.) and their records.
  10. Check food and water supplies.
  11. Monitor radio.
  12. Have a plan in place for pharmaceuticals with (pharmacy name) and an alternate source to determine emergency operations in the event of halted deliveries or the need for backup.
  13. Warn staff and residents of the situation and expedient protective measures.  Schedule extended shifts for essential staff.  Alert alternate personnel to be on stand-by.

 

C.  Response

In response to an actual emergency situation, the facility Administrator will coordinate the following actions:

  1. Complete the actions of Pre-emergency and Preparedness outlined above.
  2. Activate the Disaster Preparedness Plan and conduct Command Post operations, including communications, message control and routing of essential information.
  3. Ensure communications with residents’ families and physicians.
  4. Determine requirements for additional resources and continue to update appropriate authorities and/or services.
  5. Coordinate actions and requests for assistance with local jurisdiction emergency services and the community.
  6. Ensure prompt transfer and protection of resident records (in case of evacuation).

 

D.   Recovery

Immediately following the emergency situation, the facility Administrator should take the provisions necessary to complete the following actions:

  1. Assess the event’s impact upon the facility, residents and staff members.
  2. Coordinate recovery operations with the local Emergency Management Agency and other local agencies to restore normal operations, to perform search and rescue, and to re-establish essential services.
  3. Provide crisis counseling for residents and families as needed.
  4. Provide local authorities a master list of displaced, missing, injured or dead; and notify the next of kin.
  5. Provide information on sanitary precautions for contaminated water and food to staff, volunteers, residents and appropriate personnel.
  6. If necessary, arrange for alternate housing or facilities.

 

IV.    ORGANIZATION AND RESPONSIBILITIES

The facility Administrator is responsible for the overall direction and control of facility emergency operations, receiving requested assistance from the heads of each internal department, the local Emergency Management Agency, local Fire Department, local Police Department, private and volunteer organizations and various local and state departments and agencies.

Duties and activities that should be directed or assigned by the Administrator are:

  1. Coordinate the development of disaster preparedness plans and procedures.
  2. Coordinate the activation, and oversee the implementation, of disaster preparedness plans and procedures.
  3. Direct Command Post operations.
  4. Assign a coordinator for the delivery of residents’ medical needs.
  5. Assign a coordinator accountable for residents, their records, and needed supplies.
  6. Assign responsibility for maintaining facility safety, including securing necessary equipment and alternative power sources.
  7. Regularly review inventory of vehicles and report to administrative services.
  8. Coordinate the emergency food services program.
  9. Ensure availability of special resident menu requirements and assess needs for additional food stocks.
  10. Assign a coordinator to ensure the cleanliness of all residents and provision of residents’ supplies for 7 to 10 days.
  11. Coordinate the inspection of essential equipment (wet/dry vacuums) and protection of facility (lower blinds, close windows, secure loose equipment, etc.).
  12. Provide security of facility/grounds.  Limit access to facility as necessary.
  13. Coordinate provision of assistance to Maintenance and Housekeeping Departments.
  14. Supervise notification of families on emergency operations.
  15. Facilitate telecommunications and oversee release of information.

EXAMPLE:  Possible organizational chart for disaster response activities.

Attachment A: Hazard Assessment

Evaluate your facility and the area surrounding it for vulnerability to each of the identified natural hazards.

Directions:  Using the rating system identified below, enter the appropriate number for your estimate of Potential Damage, Frequency of Event, and Secondary Problems.  Then, multiply each figure by the following figure to get the Total Score.  (Scores may range from 1 to 125 points.)

Potential Damage: Range 1 – 5

1 = Little or no likelihood of this event occurring in or affecting your area.

2 = Some likelihood of this event occurring in or affecting your area.

3 = Moderate likelihood of this event occurring in or affecting your area.

4 = High likelihood of this event occurring in or affecting your area.

5 = Very high likelihood of this event occurring in or affecting your area.

 

Frequency: Range 1 – 5

1 = Has not occurred in last 100 years.

2 = Happens at least once every fifty years.

3 = Happens at least once every ten years.

4 = Happens at least once every five years.

5 = Annual event, or more often.

 

Secondary Problems: Range 1 – 5

Remember, secondary effects include loss of services such as power and phone services.  It may affect roadways and access to other areas of the city.  Secondary effects may interfere with food and medical supplies being delivered to the area.

1 = No secondary effects or problems likely.

2 = At least one secondary effect, short-term in nature.

3 = Multiple secondary effects; may 2 or 3 days.  (Begins to be a problem.)

4 = Significant secondary effect(s).  May last a week.  (Is a problem.)

5 = Significant secondary effects last more than a week.  (Long-term and/or big problem.)

 

Example:

HAZARD

POTENTIAL DAMAGE

FREQUENCY

SECONDARY PROBLEMS?

TOTAL SCORE

Flood

3

(Probably will affect this area)

4

(Happens about every 5 years)

2

(Would probably cause problems, but short-term)

24

Out of a possible 125 points, this would be considered a pretty low risk.

 

 

Score your hazards now:

HAZARD

POTENTIAL DAMAGE

FREQUENCY

SECONDARY PROBLEMS?

TOTAL SCORE

Earthquake
Fire (e.g., wildfires)
Flood
Landslide
Severe Weather
Volcanic Eruption

 

Once you have completed the scoring, look at the Total Scores.  The highest number indicates what you think may be your highest risk(s).

Attachment B: Emergency Checklists

 

The following pages provide emergency response checklists for natural hazards that may occur in the Pacific Northwest.

 

B-1:  All Hazards Preparedness

Steps to be completed ahead of time:

 

 

CompletedInitials
1.   Identify and obtain emergency supplies.

  • Flashlights (and batteries)
  • Radio (and batteries)
  • Emergency food and water supplies
  • Extra blankets
  • Medications
  • First aid kit
  • Sanitation items
  • Personal care items
2.   Create and exercise an emergency communications plan.
3.   Develop and exercise an evacuation plan.  Know the evacuation route(s).
4.    Keep all vehicles (personal and facility-owned) adequately fueled.  Don’t let the tank go below half-full.
5.   Identify community partners and “sister facilities.”  Develop and maintain Mutual Aid Agreements and/or Letters of Understanding.
6.   Install flexible pipe fittings to avoid gas or water leaks. Flexible fittings will be less likely to break.
7.   Maintain an accurate blueprint of all utility lines and pipes associated with the facility and grounds.
8.    Develop procedures for emergency utility shutdown.
9.   Install and maintain a back-up generator.

 

 

B-2:  Fire Safety

 

 

Steps to be completed ahead of time (in addition to All-Hazards Preparation):

 

Completed        Initials

 

1.   Post locations of fire alarms.

 

2.   Post locations of fire extinguishers.

 

3.   Train employees on use of alarm systems and extinguishers.  (Refresh annually.)

 

4.   Post directions on how to utilize emergency equipment.

 

5.   Train on, and exercise RACE procedures:

 

RRESCUE – Rescue residents in immediate danger.

 

A:  ALARM – Sound nearest alarm if not already activated.

 

C:  CONFINE – Close doors behind you to confine the fire.  Crawl low if the exit route is blocked by smoke.

 

E:  EXTINGUISH – Utilize fire extinguisher as situation permits or

 

EVACUATE – Follow evacuation procedures.

 

 

FIRE SAFETY

 

 

During the event:

 

CompletedInitials
R:   RESCUE – Rescue residents in immediate danger.
A:   ALARM – Sound nearest alarm if not already activated.
C:   CONFINE – Close doors behind you to confine the fire.      Crawl low if the exit route is blocked by smoke.
E:   EXTINGUISH – Utilize fire extinguisher as situation permits   or
EVACUATE – Follow evacuation procedures.

 

 

B-3:  Severe Weather

Includes electrical storms, wind storms, rain storms, snow storms, etc.

 

Steps to be completed ahead of time (in addition to All-Hazards Preparation):

CompletedInitials
1.   Plug critical equipment into surge protectors.
2.   Evaluate the facility for potential dangers and fix the problems.

  •  Dead trees that could fall during the storm
  •  Potential fire hazards

 

 

 

SEVERE WEATHER

 

During the event:

 

CompletedInitials
1.    Relocate to inner areas of building as possible.
2.    Check restrooms or vacant rooms for visitors or  stranded residents.
3.    Keep away from glass windows, doors, skylights and appliances.
4.    Refrain from using telephones and taking showers.
5.    Turn off and unplug computers, televisions and other non-critical appliances.
6.    Listen to battery-operated radio for information.

 

 

B-3:  Earthquake

 

Steps to be completed ahead of time:

 

CompletedInitials
1.    Evaluate the facility for potential dangers and fix the problems.  Examples:

  •  Remove potential fire hazards
  •  Secure furniture or equipment/appliances to the wall (may fall and cause injuries)
  •  Store large and/or heavy items low to the ground
  •  Repair any deep cracks in walls, ceilings or foundation of building
  •  Bolt and strap the water heater to the wall and ground
  •  Affix pictures and/or mirrors securely
  •  Brace overhead light fixtures
2.    Train and exercise on “Drop, Cover and Hold”.

 

 

 

Earthquake

 

During the event:

 

CompletedInitials
1.   Drop, Cover and Hold
2.   Inspect the facility for safety.  Evacuate if building is not safe using RACE system.
R:   RESCUE – Rescue residents in immediate danger.
A:   ALARM – Sound nearest alarm if not already activated.
C:   CONFINE – Close doors behind you to confine the fire.      Crawl low if the exit route is blocked by smoke.
E:   EXTINGUISH – Utilize fire extinguisher as situation permits   or
EVACUATE – Follow evacuation procedures.
3.   Put out small fires quickly.  If not handled by one extinguisher, or it is larger than a wastepaper basket, evacuate the building.
4.   Check on residents, staff and visitors.  Check restrooms or vacant rooms for visitors or stranded residents.
5.   Take care of injured or trapped persons.  Provide medical treatment as appropriate.  Call 9-1-1 only for life-threatening emergencies.
6.   Turn off gas only if you smell gas or think it may be leaking.  (Natural gas line cannot be turned on again except by the gas company.)
7.   Be prepared for after-shocks and re-evaluate building safety after additional seismic activities.

 

 

B-4:  Flood

 

Steps to be completed ahead of time (in addition to All-Hazards Preparation):

 

1.   Evaluate the facility for flood hazard(s).

  • Know your flood risk and elevation above flood stage.
2.   Install check valves in building sewer traps to prevent flood water from backing up into building drains.
3.   Have sand and sandbags on hand to ward off floodwaters.  Train on sandbagging techniques.
4.    Invest in flood insurance by either calling the National Flood Insurance Program at (800) 427-4661 or contacting your local insurance agent.

 

 

 

FLOOD

During the event:

 

1.   When warned of potential flooding, fill clean bathtubs, large pans, buckets, etc., with fresh water and store in case water services are interrupted (contaminated).
2.   Fill and use sandbags to ward off floodwaters.  Use proper sandbagging techniques.
3.   Evacuate according to local emergency management orders and/or recommendations.
4.   Turn off electricity if the building is flooded.

 

 

After the event:

1.  Clean.

  • Wear dusk mask and gloves.
  • Get rid of mud as soon as possible.
  • Clean everything that got wet.
  • Don’t risk contamination.  “If in doubt, throw it out.”
  • (A solution of one part household bleach and four parts water will kill surface mildew and, if used as part of a regular maintenance program, will prevent mildew from returning.)
2.  Dispose of all foods and canned goods that came in contact with flood waters.
3.   Boil drinking water before using. Wells should be pumped out and the water tested for purity before drinking. If in doubt, call your local public health authority.
4.   Be cautious around electrical lines, outlets and appliances.  Do not assume that the power is off.
5.   Do not dispose of hazardous chemicals and materials (those marked “danger, caution, poison, warning, flammable, toxic, keep out of reach of children and hazardous”) in the trash, down the drain or into standing water as they can contaminate groundwater and sewer lines.  Take these items to the hazardous materials waste site in Everett.
6.   Watch for animals. Small animals like rats and snakes that have been flooded out of their homes may seek shelter in yours. Use a pole or stick to poke and turn items over and scare away small animals.
7.   Look before you step. After a flood, the ground and floors are covered with debris including broken bottles and nails. Floors and stairs that have been covered with mud can be very slippery.

 

B-5:  Landslide

 

Steps to be completed ahead of time (in addition to All-Hazards Preparation):

 

1.   Evaluate the facility for landslide hazard(s).

  • Landslide may be triggered by earthquakes or floods.
2.   Plant slopes with ground cover.
3.   Learn to recognize landslide warning signs.
4.    Landslide is often covered by flood insurance policies.  Check on the status of your policy.

 

 

LANDSLIDE

 

During the event:

1.   If inside, take cover under desk, table, or other heavy piece of furniture.
2.   If outdoors, get out of the path of the mudflow.  Try to get to high ground.  If escape is not possible, curl into a ball and protect your head.

 

After the event:

1.  Get away and stay away from slide area.
2.  Watch for flooding.
3.  Check for trapped persons near – but do not go into – the slide area.  Direct emergency response personnel to possible victims.
4.   Check building and surrounding area for damage or other safety issues, including:

  • Foundation
  • Chimney
  • Ground slopes and surrounding land
5.   Listen to local radio and TV for emergency information.
6.   Report broken utilities and damaged roadways to local authorities.
7.   Seek the advice of a geotechnical expert for evaluating landslide hazards or designing corrective techniques to reduce landslide risk.
8.   Replant ground cover as soon as possible.

 

 

B-5:  Volcanic Eruption

Most of the local hazards associated with volcanic eruption are “secondary” in nature such as ashfall and mud flows.

 

Steps to be completed ahead of time (in addition to All-Hazards Preparation):

1.    Evaluate the facility for volcanic hazard(s).  (Is your facility near a volcano or in the path of potential mud flows?)
2.   Obtain dust masks for all residents and staff.
3.   Evaluate individuals for additional breathing protection needs.

 

 

During and after the event:

1.   Monitor local radio and TV for current information.
2.   Follow safety directions from emergency responders.
3.   Stay indoors with windows and doors shut.  Turn off HVAC systems.  Close any chimney dampers or other vents.
4.   Use a dust mask or damp cloth over the face to help breathing.
5.   Wear long-sleeved shirts and long pants if outside.
6.   Clear roofs of ashfall. Ashfall is very heavy and can cause buildings to collapse. Exercise great caution when working on a roof.
7.   Avoid driving in heavy ashfall. Driving will stir up more ash that can clog engines and stall vehicles.  (If you must drive, keep speeds below 35 mph.)

 

 

B-6:  Power Outage

 

Steps to be completed ahead of time (in addition to All-Hazards Preparation):

1.    List names and numbers of maintenance personnel for day and evening notification.
2.    Evaluate back-up generator needs.  Consider power needs for critical safety and medical equipment, refrigeration, temperature control, etc.
3.    Arrange for private contract to serve as an added back-up source.

 

 

During the event:

1.   Call # _________________ (power company) to report outage.
2.   Notify maintenance staff.
3.   Evacuate the building if danger of fire.
4.   Keep refrigerated food and medicine storage units closed to retard spoilage.
5.   Turn off power at main control point if short is suspected.

 

 

 

B-7:  Water Main Break

During the event:

1.   Call # _________________ (water company) to report outage.
2.   Notify maintenance staff.
3.   Evacuate the building if necessary.
4.   Shut off valve at primary control point.

 

 

 

B-8:  Gas Line Break

During the event:

1.   Call 9-1-1.
1.   Evacuate the building immediately.  Follow evacuation procedures.
2.   Shut off main valve.
3.   Call # _________________ (gas company) to report break.
4.   Notify maintenance staff.
5.   Open windows and doors.
6.   Re-enter building only at the discretion of utility officials.

 

 

 

 

Attachment C: Standard Operating Procedures

 

This section should include procedures and information for:

 

  • Notification Check Lists

 

  • Emergency Call Down Roster (for Staff)

 

  • Task Assignments (by position)

 

  • Emergency Supplies: Storage, Maintenance and Use

 

  • Security Procedures

 

  • Evacuation Procedures

 

  • Emergency Generator Procedures

 

Attachment D:  Mutual Aid Agreements

 

Mutual Aid Agreement contents will vary.  Some provisions to consider are:

 

  • Definitions of key terms used in the agreement

 

  • Roles and responsibilities of individual parties

 

  • Procedures for requesting and providing assistance

 

  • Procedures, authorities and rules for payment, reimbursement and cost allocations

 

  • Notification procedures

 

  • Protocols for interoperable communications

 

  • Relationships with other agreements

 

  • Workers compensation

 

  • Treatment of liability and immunity

 

  • Recognition of qualifications and certifications

 

  • Sharing agreements, as required

 

Attach copies of all Mutual Aid Agreements to this document.

 

 

Attachment E:  Contact Lists, Misc.

 

This section should include contact information for regional partners and suppliers:

 

  • Facility Maintenance and Repair

 

  • Transportation

 

  • Medical Supplies

 

  • Food and Water Supplies

 

  • Generator Fuel

 

  • Regional Partners / Non-profit Agencies (for emergency assistance)