CODE BLUE OPERATIONS In accordance with NYCDOH COVID-19

EFFECTS OF COVID-19: CODE BLUE OPERATIONS

In accordance with NYCDOH COVID-19 guidance, the following program areas are

expected to be impacted during Code Blue events of 2021/2022:

Code Blue Notifications: To assist program areas in operational expectations during

Code Blue events, DSS Emergency Management will differentiate between normal Code

Blue operations and COVID Code Blue until the pandemic is declared over (NYC DHS

CODE BLUE NOTIFICATION vs. NYC DHS COVID CODE BLUE NOTIFICATION).

Emergency Department Waiting Rooms: Due to social distancing measures, ED

waiting rooms will not be able to accommodate street homeless clients. If individual

experiencing homelessness does not need medical attention but accepts/requests DHS

Services, the ED will call the DHS Joint Command Center (see Medical Director’s memo

to hospital partners).

General Screening & Testing: COVID screening should remain in place until further

notice. Screening questions include:

1. Has client experienced any of the following with in the past 10 days: fever of 100.0

degrees Fahrenheit or greater, a new cough, loss of taste or smell, or shortness of

breath?

2. In the past 10 days, has the individual tested positive for COVID-19 using a test

that tested saliva, or used a nose/throat swab (nasal, naso-pharyngeal (NP)?

3. Have they been in close contact with anyone diagnosed with COVID-19?

4. Have they traveled internationally?

If client answers ‘yes’ to the above questions or exhibit symptoms, the client should

be sent to or recommended to be in isolation (yes to Q1-2) and tested for COVID-19

(yes to Q1). If client answers yes to Q2-3, client needs to quarantine for 14 days

since last exposure and potentially be tested. Please note, clients who respond no

to all the questions above may still not be able to stay in common areas if physical

distancing guidelines cannot be met and no shelter beds available.

Thank you & Stay safe!

DHS-PB-2021-015

OFFICE OF POLICY, PROCEDURES AND TRAINING ‒ Page 2

OFFICE OF POLICY, PROCEDURES AND TRAINING

James K. Whelan

Executive Deputy Commissioner

DHS-PB-2021-015

Subject:

Code Blue

Procedure

Applicable To:

All individuals living on the

street, Outreach

Providers, DHS Adult and Family

Shelter, Intake and Safe Havens,

Drop-in Centers, DSS & DHS Security

& Staff, DSS Emergency

Management, NYPD and other

Collaborating City Agencies

Effective Date

November 03, 2021

(Replaces Code

Blue Procedure

DHS-PB-2020-017 [R1])

Administered By:

Adult Services, Family Services, Street

Homeless Solutions, and

Emergency Management

Approved By:

Joslyn Carter,

Administrator

Department of Homeless Services

PURPOSE

This Code Blue procedure describes and directs Agency operations required for the

protection of individuals living on the street and for the prevention of injury and death

resulting from cold exposure by providing instructions concerning: (1) services provided

by Street Homeless Solutions (Outreach, Safe Havens, Stabilization Beds, and Drop-

in Centers) and DHS Shelter Operations; and (2) the provision of shelter to individuals

“reasonably believed to be homeless and unwilling or unable to find the shelter necessary

for safety and health in inclement winter weather” in accordance with New York State

Regulation 18 NYCRR § 301.4 (“Emergency Measures for the Homeless During

Inclement Winter Weather”). Consistent with New York State Regulation 18 NYCRR §

304.1, the threshold for calling a Code Blue for DHS has been revised and the actions to

be taken reflect the direction in the Regulation that shelter must be offered to all

individuals “reasonably believed to be homeless and unwilling or unable to find the

shelter necessary for safety and health in inclement winter weather.” Id.

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DSS Emergency Management (EM), with input and guidance from NYC Emergency

Management NYCEM), determines when Code Blue triggers are met based on Central

Park temperatures reaching 32

Fahrenheit (F) or below, including windchill, between the

hours of 4:00 p.m. and 8:00 a.m.

The baseline for Code Blue temperature corresponds to the New York State Regulation

and is also referred to as inclement winter weather. Code Blue will be determined daily in

order to define which hours require enhanced outreach, in addition to continuous street

outreach, so as to:

1. address the needs of vulnerable people living on the streets who are “reasonably

believed to be homeless and unwilling or unable to find the shelter necessary for

safety and health in inclement winter weather” during a Code Blue by requiring that

the outreach which normally occurs be expanded to greater frequency between

the hours of 8:00 p.m. to 8:00 a.m. and/or by requiring enhanced outreach services

as described below, which may direct and offer to move such individuals to the

appropriate shelter facility; and

2. provide shelter to individuals “reasonably believed to be homeless and unwilling or

unable to find the shelter necessary for safety and health in inclement winter

weather” in accordance with New York State regulations and administrative

directives.

II.

CODE BLUE ALERT NOTIFICATION PROCESS

DSS EM shall issue a Code Blue alert when Central Park temperatures are forecast to

reach 32

Fahrenheit (F) or below, including windchill, between the hours of 4:00 pm and

8:00 am. This will be done in coordination between New York City Emergency

Management (NYCEM) and DSS EM, who will issue the official Code Blue alert to all

stakeholders.

The following steps will take place for activating and coordinating Code Blue:

1. DSS EM will issue the official Code Blue activation by emailing

(DSSemergency@dss.nyc.gov) the Code Alert Distribution List, no later than

12pm on the day of the activation. Email notifications will contain “NYC DHS

CODE BLUE OUTREACH NOTIFICATION” in the subject line.

2. DSS EM will enter the alert into CARES to notify all shelter operators.

3. The External Affairs Unit will ensure notification of a Code Blue Alert is posted to

the DHS website and to DHS social media.

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ENHANCED OUTREACH NOTIFICATION PROCESS

When a Code Blue Alert is called, and when the following Winter Weather Emergency

conditions are forecasted, DSS Emergency Management will send notification for

Enhanced Outreach through the same Code Blue Alert process outlined above.

A Winter Weather Emergency shall be called upon forecast of any of the following

conditions for Central Park:

1. National Weather Service (NWS) predicts steady or consistent precipitation

between the hours of 4:00 p.m. and 8:00 a.m.; or

2. Snowfall is greater than six inches; or

3. Temperatures are below 15

F for a 48-hour period; or

4. Wind chills are below 0

F; or

5. There are sustained winds of more than 40 miles per hour; or

6. There are ice storms and/or freezing rain.

The notification steps will be the same as above with the following exceptions:

•

Email notifications will have “NYC DHS CODE BLUE OUTREACH

NOTIFICATION WITH ENHANCED OUTREACH” in the subject line.

•

The notification itself will state the criteria being met for enhanced outreach

(e.g. “

NWS anticipates wind chills this evening below zero degrees, meeting

Code Blue with Enhanced Outreach criteria”

)

The presence of a Winter Weather Emergency entails enhanced outreach services, as

described below.

LATE CODE BLUE NOTIFICATIONS – Due to the unpredictable nature of weather, it is

not always possible to send notifications by the 12pm deadline. To remain compliant with

our legal obligations, any forecast changes received after 12pm will be distributed to the

CodeAlert group as soon as possible.

III.

OUTREACH OPERATIONS ROLE

State regulation requires that local social services districts work with police agencies,

including the New York State Police, and state agencies to take all necessary steps to

identify individuals “reasonably believed to be homeless and unwilling or unable to find

the shelter necessary for safety and health in inclement winter weather” and to direct and

offer to move such individuals to the appropriate sheltered facilities. This requirement is

based on the State’s recognition that inclement winter weather presents a threat to the

life, health, and safety of homeless persons.

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In the same spirit and based on the goal of the State regulation, DHS’ critical death

prevention work occurs throughout the year with targeted placement of the most chronic

and vulnerable street homeless clients into housing and includes implementation of an

enhanced plan three (3) months prior to the winter months.

DHS Street Outreach during Code Blue and Winter Weather Emergencies

Regardless of the presence of a Code Blue or Winter Weather Emergency Alert, DHS

Street Outreach teams operate throughout the day and night canvassing and engaging

with individuals experiencing unsheltered street homelessness. During a Code Blue or

Winter Weather Emergency Alert, the following describes the expanded and enhanced

services provided by DHS Street Outreach teams:

1. Contact individuals on their Code Blue Priority Lists a minimum of once (1) every

four (4) hours beginning at 8:00 p.m. during Code Blue Alerts, and once (1) every

two (2) hours beginning at 8:00 p.m. for Enhanced Code Blue Alerts, to encourage

them to accept transport to a safe place. This expanded and enhanced outreach

continues from 8:00 p.m. until 8:00 a.m.

2. Offer any available NYCEM resources to clients during a Winter Weather

Emergency Alert.

3. Collaborate with agency partners when appropriate for assistance in secluded or

dangerous areas.

4. Identify and monitor at-risk clients during cold weather.

5. Assist at-risk clients to voluntarily come indoors to heated facilities or warming

centers.

6. Call 911 to request NYPD and EMS assistance for individuals with a medical or

psychiatric emergency in need of transport to an emergency room.

7. Arrange for the involuntary transport to a hospital emergency department for at-

risk clients who meet the NYS Mental Hygiene Law, section 9.58 criteria. If

outreach is unsuccessful in affecting a section 9.58 removal to a hospital and the

Outreach teams have fully utilized their organizational chain of command –

including Shift Supervisor, Program Director, and the lead medical

professional/Agency Medical Director for the organization – they may contact the

DHS Medical Director’s Office for support, in particular if admission to a hospital

seems necessary and the hospital is not inclined to admit the patient.

8. Consult with appropriate DHS staff before bringing any clients to 30

Street or

overnight facilities in order to ensure appropriate space and staff coverage.

DHS Street Outreach Teams’ Administrative Role

In addition to the enhanced services offered to clients during a Code Blue/Winter Weather

Emergency Alert, DHS Street Outreach teams shall also have the following administrative

roles:

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1. Create and submit a 24-hour coverage plan with adequate staff coverage taking

into account the coldest, most severe part of the day (usually overnight) to DHS

SHS;

2. Add additional vans operating on the overnight shift in each borough;

3. Submit to DHS SHS Code Blue Recording Indicator numbers by 9:00 a.m. each

morning. Recording indicators, established at the beginning of the winter, are listed

in Appendix II.

V. DROP-IN CENTERS, ADULT AND FAMILY SHELTERS, EMERGENCY

DEPARTMENTS, AND INTERAGENCY COLLABORATORS’ ROLE

During a Code Blue/Winter Weather Emergency Alert, DHS-operated or contracted Drop-

In Centers and Shelters shall implement the following additional services and/or

standards:

1. DHS Drop-In Centers

During a Code Blue Alert, Drop-In Centers are required to accept all clients within

fire safety and health code regulations. All efforts will be made to keep clients at

the Drop-In Centers where they entered. If a Drop-In Center cannot accommodate

an individual who enters the facility during a Code Blue because of health and

safety regulations, the Drop-In Center will identify an alternative location, such as

a shelter, a warming center, or another Drop-In Center.

2. DHS Adult Shelters, Family Shelters, and Street Homeless Solutions Safe

Havens and Stabilization Beds

A. Clients currently in shelter:

i. Shelters shall not suspend or discharge any clients via sanction (see

18 NYCRR 352.35) during any Code Blue Alert period.

ii. Any clients whose shelter has been temporarily discontinued

through a sanction (see 18 NYCRR 352.35) may return to shelter

during any Code Blue Alert period.

iii. In accordance with prior directives, clients found ineligible for shelter

because they are not reasonably believed to be homeless pursuant

to New York State regulations and administrative directives and

served with 4002 notices do not need to exit shelter until the morning

following service of such 4002 notice.

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iv. In accordance with prior directives regarding providing daytime

programming, no shelter shall require any client in receipt of

temporary housing assistance to leave shelter during daytime hours.

Recreational space, waiting rooms, and other common areas may

be offered to clients if dorm rooms require cleaning. If space in

common areas is too limited to accommodate the residents

remaining in shelter during the day, shelters should permit clients to

remain in the dorm rooms.

Note: This policy is not limited to code blue situations, and is

standard DHS practice throughout the year.

B. Clients returning to shelter: In accordance with New York State Regulation

18 N.Y.C.R.R. § 304.1, during Winter Weather Emergency periods, as

described in Section III above, single adult shelter clients may access any

single adult shelter to seek a shelter bed. At all other times, single adult

shelter clients who already have a shelter assignment must return to their

official shelter. This does not include late arrival facilities or quarantine

sites. Upon arrival to such shelter, staff will check in with Vacancy

Control to determine if a vacancy exists and, if so, the client will be given

a bed. If no bed is available, the client will be given the option to remain

at the shelter and be accommodated in the waiting room, or be transferred

to another shelter where an overnight bed exists.

C. Outreach and/or new walk-in clients to shelter/Safe Haven: Shelters/Safe

Havens/Stabilization Beds will make beds available to accommodate

individuals brought in by DHS Street Outreach teams or who walk-in on

their own. All such individuals will be engaged by shelter/safe haven case

workers the following morning in an effort to encourage them to stay indoors

and access services. In the event a bed is not available, a client will be able

to remain in the facility in a designated area, as a bed may not be available.

D. All clients: Shelters will store clients’ belongings overnight.

E. In the event of a Priority One incident, requiring a need for safety transfer,

the client will be transferred immediately at the end of the current Code Blue

event (unless an extreme case exists for an immediate transfer).

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3. Hospital Emergency Departments

The DHS Medical Director’s Office shall release an annual letter to NYC Health &

Hospitals and the Greater New York Hospital Association to request their

cooperation (Appendix III) during Code Blue/Winter Weather Emergency Alerts.

Hospitals will allow street homeless individuals, brought in by outreach or who walk

in on their own, to stay in emergency department waiting rooms (or other areas as

designated by the particular institution), as much as possible, without being

registered, unless they present with a medical need or ask to be seen by a medical

provider.

4. Interagency Collaboration

DHS shall coordinate with the following NYC agencies to identify and report at-risk

homeless individuals, and involuntary removals, when appropriate:

NYPD and/or Parks Enforcement

Patrol (PEP)

MTA – NYC Transit

NYC Sheriff’s Dept.

Department of Sanitation, NYC

Port Authority OEM

Fire Department, NYC

DHS shall also inform its Encampment Agency partners of a Code Blue Alert:

NYC Department of

Sanitation

Department of Buildings

NYC Parks Department

Department of Transportation

NYC Department of

Education

311 Service Requests - How does the 311 process change during Code Blue?

•

Homeless Person Assistance service requests become “Homeless Person in

Need of Immediate Attention” service inquiries during Code Blue.

•

311 phone calls are routed directly to 911. If the public attempts to make a

Homeless Person Assistance service request via the 311call center during Code

Blue, the call taker explains the following:

•

911 accepts reports of homeless people who are:

•

Outside during weather emergencies

•

Creating a hazard, such as blocking a sidewalk or ATM

•

Outstretched or sleeping in a subway, on the tracks, or in another Transit

District area

•

Creating a danger to themselves or others

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•

The 311 mobile app does not allow users to submit requests; instead, users are

prompted to call 911 to request assistance for a homeless person with the

following message, “Extreme cold weather activates a Code Blue period from 4

pm to 8 am. During this time, 311 Street Homeless Service Requests are routed

directly to 911”

•

Any 311/911 concerns during a Cold Weather event, should be directed to 911.

VI. CODE BLUE PLANNING

During the non-winter months, DSS & DHS engage in Code Blue Planning to prepare for

the subsequent winter season, as follows:

DSS Emergency Management’s Role

1. Reviews and revises the Code Blue procedure as needed.

2. Requests training from DOHMH on NYS Mental Hygiene Law, section 9.58

removals.

3. Initiates a conference call to Emergency Management Leaders to facilitate

procedure maintenance, identifies the process for approval, walks through

the Winter Weather Season, and provides updates to the group.

4. Maintains the CodeAlert Distribution List. Any individuals that would like to

receive Code Blue Notifications must email the DSS Emergency

Management mailbox (DSSEmergency@dss.nyc.gov).

5. Share procedure with NYC Emergency Management at the start of the Code

Blue season for situational awareness.

DHS Street Homeless Solutions Unit’s Role

During the first week in November each year, the DHS SHS and Medical Director’s

Office, together with the DSS OPPM and OLA shall review the Code Blue Procedure.

When the Code Blue Procedure is finalized and approved, DHS SHS shall:

1. Review the procedure with outreach team directors and discuss winter

preparedness. Training(s) may be offered on identification and assessment

of at-risk clients and resources.

2. Facilitate conference calls with outreach teams to identify areas of

collaboration and/or the need for more support.

3. Notify outreach teams when Code Blue with enhanced outreach is

implemented.

4. Coordinate with other Agencies. DHS reviews the Code Blue procedure with

partner agencies, such as DSNY and the Parks Department, and solicits their

help with encouraging individuals to come inside during Code Blue events.

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The DHS-contracted outreach teams conduct the following prevention planning:

1. Coordinate Code Blue efforts directly with agencies, such as DSNY and the

Parks Department, at a borough level.

2. Develop a Code Blue Priority List in October.

a. The Code Blue Priority list may be updated throughout the winter when

other at-risk clients are identified.

Appendix I

Contact Information for DHS Outreach Teams

Bronx Outreach BronxWorks

24-hour number: 718- 893-3606

Director: Juan Rivera jrivera@bronxworks.org

Brooklyn/Queens Street to Home Breaking Ground

24-hour number: Brooklyn: Casey Burke 917-753-

1837

cburke@breakingground.org

Queens: Cara Ochsenreiter 631-875-4353

cochsenreiter@breakingground.org

Director: Chris Tabellario ctabellario@breakingground.org

Manhattan Outreach Consortium CUCS

24-hour number:

212-222-9806

Director: Erica Strang

212-724-1001 or estrang@cucs.org

Staten Island

Project Hospitality

24-hour number:

347-538-2314

Director: Teisha Diallo

teisha_diallo@projecthospitality.org

MTA Outreach

BRC

24-hour number:

212-533-5151

Director: Tim Long

tlong@brc.org

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Code Blue Shift Indicators

Number of Vulnerable Clients on Priority List

Number of Vulnerable Clients Contacted

Total Number of Contacts with Vulnerable Clients

Number of Voluntary Placements to Shelter, Transitional Housing, Drop-In Centers, or

Permanent Housing (already housed),

Number of Voluntary Placements to Hospital ERs for Medical Issues

Number of Voluntary Placements to Hospital ERs or Waiting Rooms for shelter only

Number of Voluntary Placements to Warming Centers, and of those

Number of Voluntary Placements to Other Warm Spaces

Number of 911 calls

Number of 9.58 removals

Number of EDP Involuntary Removals with NYPD

Number of Subway Teams in the Field

Number of Code Blue Stations (Subway Outreach Only)

Number of Visits to the Code Blue Stations (Subway Outreach Only)

Number of Contacts that the Staten Island Ferry Terminal (Staten Island Only

Important Notes or Significant Information

Appendix II

Code Blue Indicators

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Appendix III

Assessing Clients during a Code Blue

A. At all times, but especially when the weather is dangerous (extreme cold, rain, snow,

etc.), all people living on the streets should be assessed using the following

Vulnerability Index

• More than three (3) hospitalizations or emergency room visits in the last

year

• More than three (3) emergency room visits in the previous three (3) months

• Aged 60 or older

• Cirrhosis of the liver

• End-stage renal disease

• History of frostbite, immersion foot, or hypothermia;

• HIV/AIDS

• Tri-morbidity: co-occurring psychiatric, substance use disorder, and

chronic medical condition

In addition, determine whether or not the following characteristics are present:

• Exposure to the elements:

Living conditions (structure or lack thereof)

Appropriate dress (layering, and head, hands, and feet covered)

• Open fires, “contained fires”, and the risk for carbon monoxide poisoning

• Ability to be logical and goal-directed toward meeting basic needs

• Active signs of hallucinations or gross disorganization

• Alcohol dependence (current)

• Known history of heart disease, diabetes, peripheral vascular disease

and/or severe psychiatric illness

B. Outreach teams should keep the Code Blue Priority List in their vans and at the office

to ensure clients are visited in accordance with the operational standards referenced

in Code Blue.

C. Call NYPD for at-risk individuals who refuse to come indoors and who do not

meet the NYS Mental Hygiene Law, section 9.58, or EMS threshold for

involuntary transport.

Community Solutions, James J. Connell, 2007. Vulnerability Index.

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D. Frostbite Detection Guide to Determine if a Need for Medical Attention Outreach

Teams should visit people on the streets and at-risk on a regular basis.

1. To assess for frostbite, here are three (3) questions that must be asked when the

temperature is below 32

a. Are you experiencing pins-and-needles sensation in your fingers, toes,

nose, or ears?

b. Is your skin on your fingers, toes, nose, or ears turning a shade of white?

c. Is the skin on your fingers, toes, nose, or ears softer than usual?

2. If the person has answered YES to any ONE (1) of the questions above, then

he/she may be experiencing frostnip. Proceed to next series of questions:

a. Have you recently had (in the past day) or do you presently have any blisters

on your fingers, toes, nose, or ears?

b. Do your fingers, toes, nose, or ears feel numb, waxy, or frozen?

3. If the person has answered YES to either ONE (1) of these two questions please

assist the client to get indoors (shelter, emergency room, etc.) as he/she is

experiencing superficial frostbite and is at high risk for deep frostbite. If the client

refuses to go with the team, the team should call 911 and describe the

symptoms of incipient frostbite to the dispatcher.

E. Hypothermia – SIGNS AND SYMPTOMS

Hypothermia is marked by unusually low body temperature (below 96 F), which is well

below the body’s normal temperature of 98.6 F. Severe hypothermia can cause irregular

heartbeat leading to heart failure and death. Hypothermia usually comes on gradually;

often people are not aware that they need medical attention. Symptoms take effect in

three (3) stages:

1. Mild hypothermia: bouts of shivering; grogginess; muddled thinking

2. Moderate hypothermia: violent shivering or shivering which suddenly stops;

inability to think and pay attention; slow and shallow breathing; slow or weak pulse

3. Severe hypothermia: shivering stops; loss of consciousness; little or no breathing;

weak, irregular or non-existent pulse

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WHAT TO DO:

• CALL 911 for any degree of suspected hypothermia, describe the person’s condition

to the dispatcher.

• If the affected person is alert and able to swallow, have the person drink a warm,

nonalcoholic beverage to help warm the body.

• Move the person out of the cold. Preventing additional heat loss is crucial. If unable to

move the person out of the cold, shield the person from the cold as best as you can.

• Remove wet clothing and replace it with a dry covering. Cover the person’s head. Try

not to move the person too much. Cut away wet clothing if necessary.

• Insulate the person’s body from the cold ground. Lay the person face-up on a blanket

or warm surface.

• Monitor breathing. A person with severe hypothermia may appear unconscious with

no apparent signs of pulse or breathing. If the person’s breathing has stopped or

appears dangerously low or shallow, administer naloxone, if you are a certified Opioid

Overdose Responder. If the person is unresponsive, begin CPR, and administer

naloxone, if trained.

WHAT NOT TO DO:

• Don’t apply heat to arms and legs or give the person a hot bath. This could force cold

blood back toward the heart, lungs and brain causing the core body temperature to

drop. This can cause death.

• Don’t massage or rub the person. People with hypothermia should be handled gently

because they are at risk of cardiac arrest.

Don’t provide alcoholic beverages. Alcohol lowers the body’s ability to retain heat.

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Appendix IV