Use this SOP to keep emergency equipment and medications ready for immediate use, guide the clinic's response until local emergency medical services (EMS) arrive, and support CalOptima and DHCS Facility Site Review readiness.

📚 Resources Needed

  • The current Emergency Supplies Inventory Checklist

  • The emergency equipment and medication monthly inspection log or checklist

  • Current medication dosage charts appropriate to the patient population served

  • The site-specific written emergency response procedure and access to call 911

  • Keys or staff access controls for the locked Medical Assistant (MA) Room

✅ Before You Start

  • Confirm all emergency equipment and medications are kept together in close, usable proximity in the locked MA Room.

  • Confirm the MA Room is accessible only to staff and is not accessible to patients, customers, or unauthorized persons.

  • Confirm staff can reach every emergency item, including oxygen, without locating a step stool, ladder, or other assistive device.

  • Confirm the emergency supplies, medication dosage charts, oxygen system, airway devices, and replacement plan match the patient population served.

  • Confirm team members know the site-specific response procedure, who is CPR-certified, and that a patient or customer is never left alone during an emergency.

🚀 Tips & Tricks

  • View the medical emergency action plan here.

  • Keep the monthly inspection log beside the emergency inventory so the check is completed and documented in one workflow.

  • Mark the oxygen replacement threshold clearly and schedule replacement before the tank reaches less than three-quarters full.

  • Keep oxygen tubing beside the tank even when it is not connected.

  • After any emergency use, assign one staff member to replace every used item immediately.

  • Practice the response procedure so staff can call 911, stay with the patient or customer, and bring equipment without leaving the person alone.

📘 Instructions

Step 1: Store Emergency Equipment In The Locked MA Room

  • Keep all emergency equipment and medications together in close, usable proximity in the locked MA Room.

  • Keep the MA Room locked and limited to staff access. Patients, customers, and unauthorized persons are not allowed in the room.

  • Do not store emergency equipment or medications in a patient exam room.

  • Arrange equipment so authorized personnel can reach it immediately, including the oxygen system, without locating a step stool, ladder, or other assistive device.

  • Maintain staff access to the locked room during all operating hours so the lock does not delay an emergency response.

Step 2: Check And Document Equipment At Least Monthly

  • Check emergency medications and equipment at least monthly and retain documented evidence of the check.

  • Use a log, checklist, or another appropriate method to record the date, items checked, deficiencies identified, corrective action, and the staff member completing the check.

  • Verify that equipment and medications are maintained, ready for immediate use, and appropriate for the patient population served, using the Emergency Supplies Inventory Checklist.

Step 3: Replace Equipment And Medications After Use

  • Immediately replace any emergency equipment or medication after it is used.

  • Do not return the emergency kit or crash cart to ready status until every used, opened, missing, damaged, or expired item has been replaced.

Step 4: Maintain Oxygen And Airway Equipment

  • Maintain every oxygen delivery system so it can be regulated up to 6 liters of oxygen per minute for a minimum of 15 minutes. This requires a minimum total oxygen delivery capacity of 90 liters.

  • Replace masks when they can no longer make a solid seal.

  • Keep various sizes of airway devices onsite that are appropriate for the patient population served.

  • Maintain a method or system for oxygen tank replacement.

  • If an oxygen tank is less than three-quarters full at the time of a site visit, maintain a backup method for supplying oxygen if needed and a scheduled plan for tank replacement.

  • Oxygen tubing does not need to remain connected to the tank, but it must be kept in close proximity to the tank.

  • Health care personnel at the site must be able to demonstrate how to turn on the oxygen tank.

Step 5: Maintain The Minimum Emergency Medication And Supply Inventory

  • Maintain emergency equipment and medications appropriate to the patient population served.

  • At minimum, stock Epinephrine 1:1000 injectable; Benadryl 25 mg oral or Benadryl 50 mg/ml injectable; Naloxone; chewable aspirin 81 mg; nitroglycerin spray or tablet; bronchodilator medication as a solution for a nebulizer or a metered dose inhaler; glucose; appropriate sizes of ESIP needles and syringes; and alcohol wipes.

  • Use the current Emergency Supplies Inventory Checklist when confirming required quantities, sizes, and population-specific supplies.

Step 6: Maintain Current Medication Dosage Charts

  • Maintain a current medication dosage chart that allows staff to readily identify the correct dosage for the population served, such as infant, pediatric, or adult dosing.

  • Package inserts are not acceptable substitutes for medication dosage charts.

  • Every emergency medication in the emergency kit or crash cart must have an applicable dosage chart.

Step 7: Provide Immediate Care And Call EMS

  • Maintain a written site-specific procedure for providing immediate emergent medical care onsite until local EMS arrives.

  • Staff must be able to describe the site's specific emergency actions and procedures.

  • When the MD or NPMP is not onsite, staff or an MA may call 911.

  • CPR-certified staff may initiate CPR when needed.

  • Non-CPR-certified staff may only call 911 and stay with the patient or customer until help arrives.

  • A patient or customer must never be left alone or unattended at any time during an emergency. A staff member remains with the person until EMS arrives and care is transferred.

Step 8: Train Staff And Review Readiness

  • Train staff on the location of the locked MA Room, staff access, monthly checks, oxygen operation, the site-specific response procedure, calling 911, CPR role limits, and the requirement to remain with the patient or customer.

  • Confirm that health care personnel can demonstrate how to turn on the oxygen tank and that staff can describe the site-specific emergency response.

  • Review this SOP after an emergency, equipment use, failed monthly check, inventory change, patient population change, staffing change, or change to the MA Room or access controls.

🛠 Troubleshooting

The Locked MA Room Cannot Be Accessed Immediately

Call 911 and begin the site-specific emergency response without delay. Notify the responsible leader immediately, maintain continuous attendance with the patient or customer, and correct the access problem before normal operations continue.

An Oxygen Tank Is Less Than Three-Quarters Full

Confirm the backup method for supplying oxygen is available, schedule tank replacement, and document the replacement plan.

A Used Missing Damaged Or Expired Item Is Found

Replace the item immediately and document the deficiency and corrective action. Do not mark the kit or crash cart ready until the required item is available.

A Patient Or Customer Is Alone During An Emergency

Assign a staff member to stay continuously with the person at once. Other staff members call 911, bring equipment, and coordinate access for EMS without leaving the patient or customer unattended.

A Staff Member Is Not CPR-Certified

The staff member may call 911 and must stay with the patient or customer until help arrives. CPR may be initiated only by CPR-certified staff when needed.

✅ Completion Check

• All emergency equipment and medications are together in the locked, staff-only MA Room and are immediately accessible to personnel.

• No emergency equipment or medication is stored in a patient exam room or an area accessible to patients, customers, or unauthorized persons.

• The monthly inspection is documented and all equipment and medications are ready for immediate use and appropriate to the patient population served.

• Used, opened, missing, damaged, or expired equipment and medications have been replaced immediately.

• The oxygen system delivers up to 6 liters per minute for at least 15 minutes, providing at least 90 liters of total capacity.

• Masks seal properly, population-appropriate airway devices are onsite, oxygen tubing is close to the tank, and the replacement method is in place.

• If a tank is less than three-quarters full, backup oxygen and a scheduled replacement plan are available.

• Health care personnel can demonstrate how to turn on the oxygen tank.

• The minimum emergency medication and supply inventory is complete.

• Current dosage charts are available for every emergency medication; package inserts are not being used as dosage charts.

• Staff can describe the written site-specific response, call 911 within their role, and follow CPR certification limits.

• Staff understand that a patient or customer is never left alone or unattended during an emergency.


References

CalOptima Health Facility Site And Medical Record Review Audit Packet: Emergency Equipment And Response Protocol, page 29

Emergency Supplies Inventory Checklist

Source Protocol Revision: Apr 28, 2026

Internal readiness SOP only; the full CalOptima, DHCS, EMS, medication, and equipment requirements control.