Long-Term Care Facilities in Emergency Preparedness Planning

An important part of community emergency preparedness planning includes long-term care facilities such as nursing homes, dialysis, home care centers, or hospice facilities. Older adults and those with disabilities have increased vulnerability during emergencies. This population may have more limitations, require additional support, and may experience health emergencies sooner than others when faced with limited food, drink, rest, or access to electricity.

Concerns include the need for large-scale transportation for patients, which may require continuous care during transport, along with the ability to be moved in a nontraditional manner (i.e., patients may not be able to sit up). Complications may include: (1) the need to reach and communicate with individuals that can make decisions for any impaired patient population, (2) the need for electricity for durable medical equipment to keep patients healthy, and (3) temperature requirements for necessary medications. Based on the type of care these facilities provide, preparing for emergencies is simply not as high a priority as others they face daily.

During impending emergencies, when there is time to plan (e.g., hurricanes), each facility decides to evacuate its residents or shelter in place. Whichever action it chooses, each decision comes with unique challenges due to the complex care that most residents require. Sheltering in place means that providers need training and skills to manage the post-event complications that can occur. Evacuation requires strong planning and community coordination to ensure the safety of the residents before, during, and after transport.

In 2016, the Centers for Medicare & Medicaid Services (CMS) published the “Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers.” The rule impacted 17 different types of providers and suppliers.

However, in 2017, the U.S. Senate Committee on Finance published a report showing critical safety failures on behalf of nursing homes in Texas and Florida during and after Hurricanes Harvey and Irma. The report also notes that one county medical examiner ruled the deaths of 12 seniors in Florida as homicide, as they died due to heat-related complications when plans were not in place to accommodate the loss of their air conditioner for several days. The report additionally discusses the flooding in Texas due to Hurricane Harvey and the struggles at two nursing homes. One nursing home was evacuated only after pictures of the residents in waist-deep water circulated on social media. Another nursing home was evacuated only when someone held the director at gunpoint. The director was later arrested when he refused to assist with the evacuation.

In 2020, CMS released updated guidance to the 2016 rule, which included revisions due to the recent COVID-19 pandemic. The rule has requirements for both human-caused and natural disasters. Each provider requires four elements of emergency preparedness:

• Risk assessment and emergency planning,
• Policies and procedures,
• Communication plan, and
• Training and testing.

In 2021, CMS again released additional guidance to the 2016 rule, reducing the frequency of some emergency preparedness activity requirements and revising timelines for certain providers and suppliers. Emergency programs were decreased to a biennial review (from annually) for certain facilities, but this does not apply to long-term care facilities. While the training requirement decreased from yearly to every two years for certain providers, nursing homes are still required to keep the annual training.

In February 2022 – in response to the COVID-19 pandemic, climate change, and specific instances where long-term care struggled to manage an emergency – the White House released its reform fact sheet, which notes protecting seniors through strengthening emergency preparedness initiatives. Increasing emergency preparedness efforts in long-term care facilities can help minimize injury, illness, and preventable deaths.

Risk Assessment and Emergency Planning

Taken directly from its website, CMS requires that all risk assessment and emergency planning for long-term care facilities include the following elements:

• Hazards likely in a geographic area;
• Care-related emergencies;
• Equipment and power failures;
• Interruption in communications, including cyberattacks;
• Loss of all or a portion of a facility;
• Loss of all or a portion of supplies; and
• The plan should be reviewed and updated at least annually.

Plans should follow the industry standard of using the all-hazards approach, including building plans to address a broad spectrum of emergency events or disasters. Consideration should be given to natural and human-caused emergencies, including hurricanes, tornadoes, earthquakes, cyberattacks, loss of essential supplies such as food and water, equipment/power failures, and loss of portions of the facility.

The National Association for Home Care & Hospice (NAHC) published an emergency preparedness packet in 2008 for home health agencies. This document provides a detailed analysis for facilities to identify areas that need to be addressed within their emergency plans. This packet has a template that facilities can use for their assessment, beginning with identifying the probability of specific emergencies such as ice, flooding, terrorist attacks, and electrical failures. For a higher-level overview, facilities can also use a Hazard Vulnerability Analysis (HVA) tool, such as the one created by Kaiser Permanente, to assess areas of risk that need to be considered in emergency planning. This tool helps each facility identify considerations, including probability, human impact, property impact, business impact, preparedness, internal response, and external response. Due to the age of the NAHC document (and the lack of an updated one on its website), it is important for facilities to think about cyberattacks and whether or not they are prepared. While not specifically noted in the packet, this scenario could be considered under vulnerability in terms of the terrorism section of the HVA.

The Federal Emergency Management Agency (FEMA) also provides a Comprehensive Preparedness Guide, which reminds facilities of the need to engage the entire community in planning so that decisions reflect the actual community population. Risks should be analyzed using the question, “What could go wrong?” when building contingencies. Supplies and resources should be noted, along with any gaps that must be addressed before an emergency. The Centers for Disease Control (CDC) published a COVID-19 preparedness checklist for nursing homes and other long-term care facilities. This checklist includes several areas, including staffing contingency plans, communication protocols for interfacility transfers, and post-mortem care. CMS also published a State Operations Manual that provides emergency preparedness information for several types of providers and suppliers.

Building and Communicating a Strong Plan, Policies, and Procedures

Each facility needs to have a dedicated owner of the emergency plan. While this position is not dictated by federal law, it is a necessary step in setting up each facility for success in minimizing loss of life and property during an event. Evacuation plans should be posted on all floors in a prominent location to assist employees and residents with learning exit routes in an emergency. A minimum of quarterly communication should occur to help keep the plan’s location and the exit routes fresh in each person’s mind.

To prepare the residents, the Department of Health & Human Services & CMS published the Emergency Planning Checklist for long-term care residents, their families, friends, guardians, and caregivers. Understanding this, each long-term care facility should ensure that this information is regularly communicated without the residents or their families having to specifically request it. When all involved parties are informed and aware, it builds a stronger coalition of resources and helps to ensure a smoother approach to emergency preparedness.

Each state website provides a wealth of resources for long-term facilities to build policies, procedures, and plans for emergency preparedness. Facility administration should familiarize themselves with all available resources. Reviewing neighboring state websites can also provide additional resources and considerations that may not be included in current planning. State websites have guidance that is similar from state to state, such as the following:

Missouri lists specific requirements for emergency plans in 19 CSR 30-85.022(33), giving the following structure:

• A phased response ranging from relocation within the facility to complete evacuation;
• Written instructions for evacuation of each floor, including:
  • Evacuation to areas of refuge, and
  • Floor plans showing the location of exits, fire alarm pull stations, fire extinguishers, and any areas of refuge;
• Evacuating residents from an internal area of refuge to outside the building;
• Location of additional water sources on the property;
• Procedures for the safety/comfort of residents during and after evacuation;
• Staffing;
• Staff instructions for initiating emergency services resources;
• Staff instructions for contacting alternative housing for residents;
• Responsibilities for administrative staff; and
• Understanding of who is responsible for accounting for all residents’ locations.

Colorado includes additional information within their website, like Missouri, but notes additional information such as:

• Accounting for food, water, supplies, and medications for staff and residents for both evacuating or sheltering in space;
• Determining alternate sources of energy to ensure continuity of necessities such as temperatures, lighting, sewage and waste disposal, and fire detection and extinguishment;
• Systems to track the physical location of staff and residents;
• Establishing a primary and secondary way of communication outside the facility; and
• Medical documentation plans that continue to secure resident information in compliance with HIPAA.

Several state websites also include resources specific to the probable events within their geographical location, such as hurricanes, tornadoes, earthquakes, and flooding. In recent years planning should also incorporate cyberattacks, as they are a growing and persistent threat to long-term facilities specifically and healthcare organizations overall. Dozens of long-term care facilities have been targeted by these attacks, with a $14-million dollar ransomware attack in 2019 serving as a case study. That attack impacted over 100 facilities and led to a halt in a number of critical business functions. Many long-term care facilities leave this scenario out of emergency planning due to either lack of resources and/or expertise in this area, which can result in critical loss to the facility and its residents.

Understanding the unique risks of each facility is critical for building a strong and reasonable plan. For example, if residents require communication with designated decision-makers for care, provisions should be implemented for emergencies if a decision-maker cannot be reached or it is not reasonably feasible to attempt to contact the person during the emergency event. Considerations also need to be made to address the fact that most long-term care facilities do not have a staff member specifically for cybersecurity or emergency management tasks. These duties generally fall to the administrator or their representative, placing them in a position to decide where to allocate resources: managing cases and today’s patient needs or planning for future events.

Training and Testing

Training and testing must comply with both federal and state laws and need to occur annually. Long-term care facilities are included in the National Preparedness Goal, which stresses whole community readiness for emergency events. The Homeland Security Exercise and Evaluation Program provides guidance for programs, including emergency preparedness exercises. They recommend establishing Training and Exercise Planning Workshops to engage elected and appointed officials in the emergency planning process to set appropriate priorities for each community.

The American Health Care Association created the Nursing Home Incident Command System (NCHICS) Guidebook, which can serve as a training and educational tool to better understand the organization and incident command process as it applies to each long-term care facility. The following criteria must be met for the exercise to be considered a formal drill:

• An overview of the scenario has been documented and communicated;
• The emergency preparedness plan has been activated;
• Evaluation has occurred for all areas/departments and participants;
• An after-action review/critique occurs; and
• Follow-up items/training/areas of improvement are identified, and documents and corrections are planned to close the gap.

Considerations for weather and time of year should occur when conducting trainings. Training should not be set during impending weather issues such as excessive heat, excessive cold, or the likelihood of storms. Long-term care facilities should engage community resources during exercises and drills to ensure smooth operations and continuity of care during an emergency.

Emergency Response to Long-Term Care Facilities

There are several things that first responders and emergency preparedness professionals can do to help the facilities within each community plan and prepare for emergencies. Suggestions include:

• Inviting and actively including facility leadership in community preparedness meetings;
• Collaborating with facilities on training and testing days;
• Offering to attend after-action reviews at the facility;
• Offering to review plans and assess areas of weakness;
• Asking for a tour of the facility to help identify areas of opportunity and to familiarize responders with the overall layout;
• Ensuring up-to-date plans are on file for each location with the local emergency management director; and
• Having local fire departments provide annual assistance to review fire and evacuation plans.

A review of all state websites produced a wealth of resources, including a checklist from Arizona that assists with surveying long-term care facilities. The document mentions that it is not comprehensive in developing the actual emergency plan but should be used more for researching long-term care facilities and ensuring they have adequate documentation to support emergency events.

When responding to long-term care facilities during emergencies, consideration should be given to the unique challenges that the facilities face. Having a dedicated person to own the emergency plan, as well as having a plan in place to assist with multiple limited mobility patients and understanding the increased need to monitor older people for temperature-related events, is necessary.

CMS’s Quality, Safety, and Oversight group also publishes a Special Focus Facility list, summarizing facilities with a previous history of serious quality issues. If one of these facilities is within the local community, it is important to understand the deficiencies noted and be ready to accommodate the additional issues within that population in an emergency. It is strongly suggested that these entities are actively included in community emergency preparedness coalitions and training. Engaging high-risk populations empowers local communities to build strong emergency preparedness and response capabilities while minimizing the risk of preventable injuries, illnesses, and death.