|Description of Federal Requirements|
|Comparison of State Requirements|
|Table Comparing States|
|Complete Transcript of State Requirements on Disaster & Emergency Preparedness (PDF)|
|Federal Regulations & Related F-tags for 483.75||Applicable Federal Regulation|
The federal rule for (m) Disaster and Emergency Preparedness has two components: 1) that a facility must have detailed written plans and procedures to meet all potential emergencies and disasters, such as fire, severe weather, and missing residents and 2) that the facility must train all employees in emergency procedures when they begin to work in the facility, periodically review the procedures with existing staff, and carry out unannounced staff drills using those procedures.
NOTE: The examples below may not list all States with similar language; always check your state for specifics.
The federal requirements for emergency preparedness are sparse. These minimal requirements have allowed the level of regulation at the state level to vary significantly, from silence to elaborate requirements. Also, the well publicized tragedies of the last five years associated with hurricanes (including loss of life in instances when the facility “sheltered in place,” and loss of life when the facility attempted evacuation) have highlighted this topic. Building on deficits noted during Hurricane Rita and Hurricane Katrina, popular media has especially given attention to the adequacy of nursing home evacuation plans and agreements with transportation resources, none of which are handled in federal regulation. Perhaps the heightened attention will lead to new Federal regulations in the future. In a project involving all 8 Gulf States, nursing home leaders and public health leaders collaborated to develop a better way to protect nursing home residents in future hurricanes. [Click to view an article by Brown, L. M., Hyer, K., and Polivka-West, L (2007). A Comparative Study of Laws, Rules, Codes and Other Influences on Nursing Homes’ Disaster Preparedness in the Gulf States, Behavioral Sciences Law, 25, 655-675] [NH Regs Plus Comment: We found no State currently had a specific regulation about contracts for transportation for evacuations, although such transportation arrangements. Such plans ended up being inoperable in recent large-scale disasters because all nursing homes had contracted with the same few companies, and/or federal or State emergency authorities had commandeered all the available vehicles.]
All states, including Washington, D.C. have Disater Preparedness requirements beyond the Federal regulations. Colorado (in-service education), Kentucky (Disaster plans & Procedures), Maryland (specifies training for personnel), Maine (in-service training once a year), New Hampshire (definition of an emergency), North Dakota (slight addition to training & content of emergency plans), and Oklahoma (each nursing station will have a copy of the emergency procedures). The most common additions to the minimum federal requirements are requirements that preparedness plans be detailed and some specificity about in-service education.
Regulations on emergencies tend to addresses only how a nursing home would respond to a situation that would make the facility uninhabitable, either by fire, weather, or other occurrence. California, on the other hand, also specifies that the facility must make plans for a mass ingress of disaster victims, in case the Nursing Home must accept many new patients. Florida stipulates that written disaster and emergency plans and procedures must be created for either internally or externally created disasters.
The federal requirements state that the nursing homes must be prepared for all potential emergencies, but specify drills only for fire emergencies. Some State regulations specifically mention other disasters such as hurricanes, earthquakes, or tornados. Some States include a long list of potential natural and man-made disasters, including gas explosions, nuclear power plant leaks, and epidemics. The State of Washingon requires that the plan include, at a minimum, 11 types of emergencies or disasters, including: a) fire or smoke; (b) severe weather; (c) loss of power; (d) earthquake; (e) explosion; (f) missing resident, elopement; (g) loss of normal water supply; (h) bomb threats; (i) armed individuals; (j) gas leak, or loss of service; and (k) loss of heat supply. Ohio includes “accidents pertaining to airports, trains, and chemical plants” in its shorter list. Some States in hurricane prone areas, including Alabama and Mississippi, do not specify the need for hurricane preparedness in their regulation. States sometimes require that evacuation routes within the facility be posted in specific places. California includes a provision for ID-tags for residents in the case of evacuation. A number of States include language that requires the nursing home to be linked to local disaster preparedness programs.
The remainder of this section is organized in the following categories: fire-preparedness and drills; natural disaster preparedness and drills; disaster/emergency in-service training; and equipment and supplies.
Fire Preparedness and Drills [TOP] (TOP) (NEXT)
Overwhelmingly, state preparation for emergency for drills is focused in fire drills. Most States specify a certain number of fire drills to be carried out, and some indicate how they should be divided by shift. Oregon and Utah require that a certain number of drills be carried out in conjunction with the local fire marshal.
The most usual specification is that fire drills will occur quarterly (or every three months) and on each shift for a total of twelve fire drills per year. No states require more than 12 fire drills per year. The lowest required number of drills per year, when it is specified, is Montana (once per year). Ohio and Utah do not specify annual drills, but some have additional required disaster drills to prepare for tornados or other natural disaster. At the low end of required drills are Montana (1 per year), and New York (2 per year). Ohio specifies that fire drills are to take place 12 times a year as well as two additional disaster preparedness drills (one being specifically a tornado). On the other hand, Ohio regulations state that staff are not required to move bedridden residents during their drills. [NH Regs Plus Comment: The question of the right number of fire drills is not empirically answered. It occurs to us that a minimum of 12 drills may be more than needed in a facility with stable staff. On the other hand, a drill where bedridden residents are not moved may provide an inadequate test for an actual emergency.]
- North Carolina and Texas simply refer to “unannounced drills,” and North Carolina further specifies help with ventilator care during drills. Oregon does not give a number for the drills but requires that they be conducted according to the rules of the local fire marshals.
-Montana requires fire drills annually.
- New York requires fire drills twice a year. Utah also requires semi-annual drills and that they are in conjunction with “the fire board.”
-Massachusetts requires 2 drills per year for each shift.
-South Carolina requires four drills per year but does not discuss the shifts.
-Alaska, and California require quarterly fire drills and Alaska requires a record of the fire drills.
-Hawaii, Idaho, Indiana, Nevada, New Jersey, New Mexico, Ohio, Rhode Island, South Dakota, Tennessee, Virginia, West Virginia and Wisconsin require drills to be quarterly for each shifts, and, therefore 12 times a year. Additionally, New Jersey requires that the local fire department participate in one drill per year; Ohio specifies that bedridden residents do not need to be moved during drills; and New Mexico requires that its drills four times a year for each shift be at “irregular intervals,” presumably to render them unannounced.
In addition to specifying the drills, Arkansas, Illinois, Nevada, Texas and South Carolina specify that employees must be capable to operate fire extinguishing equipment. [NH Regs Plus Comment: These requirements may be somewhat antiquated, however, considering the federal mandate on sprinkler systems in most nursing facilities. But CMS has allowed homes that do not have ceiling-installed sprinkler systems to use smoke alarms instead, and therefore having training in how to use the fire extinguishing equipment would be helpful.]
-Arkansas requires 90% of staff to be familiar with the use of fire extinguishing equipment.
State regulations on natural preparedness plans and drills either specify the various kinds of natural disasters and how they are to be handled, or they leave room for more general disaster preparedness, allowing the facility to decide how it will prepared for any given emergency. Many states augment the definition of an emergency in their regulations, specifying explosions, specific natural disasters, or other acts of god in their definition of an emergency. Some states leave the definition of an emergency open, but require disaster preparedness for whatever disaster those might include.
- West Virginia requires that the Internal Disaster plan be enacted annually.
- Utah requires that the internal disaster plan be enacted semi-annually.
- Arkansas requires two tornado drills per year
- Ohio requires 2 disaster preparedness drills, one is specifically a tornado drill, which is to be held between March & July),
- Kansas specifies either one disaster or one tornado drill per year.
- Nebraska does require any drills for tornados, but it requires the facilities to have detailed written procedures for what to do in the event of a tornado and how to transport the residents.
- Florida rules do not require hurricane drills, just specifying that facilities be generally prepared for emergencies, including evacuation. However, Florida has extensive regulations for ensuring that facilities are hurricane proofed. New construction is required to be above the 100 year water level for hurricanes. Similarly, Louisiana does not specify hurricane preparedness, but requires facilities to have a plan for transporting residents to a safe location. In addition, staffs are not allowed to neglect their duties, should the patients move to another nursing home. In 2004, South Carolina gave an emergency executive order on emergency preparedness for hurricanes when previously no legislation had existed.
- Illinois specifies construction standards in areas of the State prone to earthquakes. [NH Regs Plus Comment: California does not appear to have specific earthquake resistance standards in its nursing home regulations, though perhaps these are embodied in more general State and local construction standards].
In envisaging disasters with mass casualties in the nursing home, the community, or both, several states require coordination with local mass casualty drills, e.g., Alaska and Arizona. Other States call for various degrees of integration with local emergency or public health agencies.
- Kansas requires that the written plan be coordinated with area governmental agencies, and also that facilities have agreements to provide services such as fresh water, evacuation site, and transportation.
- Utah requires facilities to establish methods of communication with local authorities.
- Rhode Island requires facilities to notify public health officials if any part of the disaster plan is activated.
- New Jersey requires a specific disaster planner to contact local government agencies and coordinate the disaster plan with the local fire department.
- Connecticut requires facilities to review their plans with the local fire marshal. Connecticut also has a requirement, enacted through a separate statute that applies to nursing homes, day centers, and child care programs, that Potassium Iodide tablets (used as an antidote for radiation poisoning) be provided to residents; this applies only to specified counties thought to be affected by a nuclear power plant.
Other than fire drills, the most common augmentations to the federal requirements are in training requirements for staff. Many States require annual in-service training in fire prevention and safety.
- Arkansas has extensive requirements for training, including that at least 90% of staff are trained quarterly fire-fighting equipment and procedures in case of fire or explosion.
- Iowa requires that the facility must train all employees in emergency procedures when they begin to work in the facility, periodically review the procedures with existing staff, and carry out unannounced staff drills using those procedures. Nevada and New York have similar language.
- Kansas require an initial orientation to emergency preparedness and then a “periodic” review of the plan.
- Idaho requires facilities to make classes for fire / safety available on a quarterly basis, but specifies that such training is not in lieu of drills.
- Maine requires that the in-service program shall be planned and include at least one program per year relating to resident rights, disaster preparedness, workplace safety and the identified educational needs of the staff. [NH Regs Plus Comment: This seems to mean that some short-term staff might work in a facility and never have been trained if they were not employed at the time of the yearly in-service program.]
- Oregon has a more extensive in-service training program requiring three hours of training per quarter, with disaster and emergency preparedness as one of the necessary topics.
- Maryland requires disaster education in in-service training and that all employees going through this training program must be able to demonstrate proficiency in emergency procedures.
Several states specify emergency power or lighting of some kind. Arkansas requires power generators and stipulates fines for non-compliance. Georgia requires an emergency food supply and emergency lighting. Iowa requires emergency lighting;Massachusetts requires an emergency electrical supply; Missouri requires both emergency lighting and a generator. Delaware requires a two-day emergency supply of food on the premises at all times.
The kind of electrical supply differs depending on what the purpose of the emergency lighting or electrical service is. If it is to provide lighting in a disaster to guide an exit from the facility, then the facility need not have extensive power. If, however, the goal is to provide normal functioning of a facility until normal service of power can resume or the utilities fix thee lines, then the requirements for generators are more extensive and can last for full or 80% functionality for 24 – 72 hours.
The Federal requirements do not state whether loss of power in itself constitutes an emergency, but some States view it that way.North Carolina notes emergency procedures for patients on ventilators during an emergency.
Some States—e.g. Wisconsin-- with heavy winters specify that facilities must keep roads and driveways clear for emergency vehicles.
Table Comparing States (TOP)
Note: If the States in this table are not hyper-linked, their provisions do not appear to address the topic, and therefore, do not alter the Federal Regulatory scope. The Table summarizes content on Disaster and Emergency Preparedness by State (with a link to each State's specific language). Link to a downloadable PDF document containing all State requirements on Disaster and Emergency Preparedness.
|State||Goes beyond Federal Regulations?||Subjects Addressed: How State Differs From or Expands On Federal Regulations|
|Alabama||Yes||Compliance with state and local laws relating to fire and safety required.|
|Alaska||Yes||Quarterly fire drills; records of fire drills; coordination with local area mass casualty drills; detailed requirements for records if nursing home provides emergency care service (e.g. shelter); written plans with local community for coordinated handling of mass emergency, including triaging. Disaster plan in place by 1/1/2007 to include: natural disaster; pandemic influenza outbreak; segregation for infection control and other measure to contain or prevent transmission of illness.|
|Arizona||Yes||Quarterly fire drills; records of fire drills; coordination with local area mass casualty drills; detailed requirements for records if nursing home provides emergency care service (e.g. shelter); written plans with local community for coordinated handling of mass emergency, including triaging. Comprehensive list of safety standards.|
|Arkansas||Yes||Training and in-service training on disaster management; at least 90% of all personnel on all shifts be trained quarterly on fire-fighting equipment and procedures for evacuation in case of fire or explosion; disaster drills, including tornado drills twice a year for all shifts; emergency generators; specific leverage of citation points for facilities that do not train staff in fire/disaster procedures and fines for noncompliance related to generators. Exceptions to minimum staffing rations when residents are relocated due to natural disaster or emergency.|
|California||Yes||Procedures for external disasters and mass casualty; including records, safe relocation, temporary emergency discharge, evacuation plan, resident ID tags, & procedures for providing emergency services to those coming in emergencies from other locations; procedures for fire and internal disasters; fire drills quarterly and disaster drills.|
|Colorado||Yes||Annual in-service training regarding disaster preparedness. Written policies for emergency services, fire and internal disaster plan and mass casualty plan.|
|Connecticut||Yes||Emergency preparedness plan, copy of which is approved by local or state fire marshal before adoption of the plan. Distribution of potassium iodide in facilities close to nuclear power plants, and contraindications for its use.|
|Delaware||Yes||The nurse's aide training in emergency procedures including curriculum content.; 2-day emergency supply of food. Submit with annual license renewal an updated Division of Public Health Residential health Care Facilities Emergency Planning Checklist.|
|District of Columbia||Yes||General safety inspections require first aid supplies available on each unit. Fire & Emergency Preparedness require a manual of action to be taken in the event of a fire, approved by the D.C. Fire Department. Required content of manual included.|
|Florida||Yes||Written disaster/emergency plan with procedures for internally or externally caused disaster; plans must be in collaboration with the Department of Community Affairs, County Emergency Management Agency; new construction standards specific for flood and water protects; sprinklers and fire-extinguishers and external emergency communications standards (e.g. on-site radio transmitters) for new construction. Fire Prevention, Fire Protection and Life Safety requirements. Information required for written report to local fire department of each fire or explosion|
|Georgia||Yes||Emergency food supply; emergency lighting.|
|Hawaii||Yes||Written disaster procedures; fire drills (with alarms) for all shifts quarterly and at least 12 per year; fire prevention rules regarding smoking and equipment.|
|Idaho||Yes||Frequency of fire drills (1 per shift per quarter); evacuation procedures; plans for temporary housing during evacuation; training of personnel for emergencies.|
|Illinois||Yes||Written disaster response plan; includes safe movement of residents within the facility in event of a tornado warning. Facility shall have a plan including proper use of a fire extinguisher, diagram of the evacuation route, moving of patients to safe locations with bad weather, official notification of severe weather. Frequency of fire drills and disaster drills and other drill specifications. Evaluation of personnel to perform these duties by drills. Special provisions provided for the evacuation procedures for persons with physical or sensory impairments. Reporting of disasters. Added construction standards in local areas prone to earthquakes or hurricanes, tornados and floods. Requirements for coordination with local authorities and annual requirements. Section on Contacting Local Law Enforcement.|
|Indiana||Yes||Specifications for frequency & particulars of fire drills. Emergency plans. Reporting of emergencies. Training on restraint behavior and facility practices.|
|Iowa||Yes||Written and posted emergency plan; training; emergency lighting and fire safety including space heaters prohibited.|
|Kansas||Yes||Providing in-service education for emergency/disaster preparedness. Written emergency plan coordinated with area governmental agencies. Agreements with local government agencies that will provide services such as fresh water, evacuation site, and transportation of residents to an evacuation site. Training and orientation.|
|Kentucky||Yes||Disaster plans and procedures. Very little added to federal language.|
|Louisiana||Yes||Detailed written Emergency preparedness and disaster plans (including evacuation of residents to a safe place, delivery of essential care and services to residents, managing staff in an emergency, transportation services for evacuating residents, and reassurance to the resident's family of evacuation of the resident).|
|Maine||No||Maine’s regulations mirror the Federal regulations. In-service training and specified at low rate of at least once a year.|
|Maryland||Yes||Specifies training for various personnel that must include emergency procedures. Extensive emergency and disaster plan including a tracking system to locate and identify residents in the event of displacement due to an emergency or disaster including a relocation plan. Identification of an emergency and disaster planning liaison for the facility. Evacuation plans, orientation and drills described in-depth.|
|Massachusetts||Yes||Written plan; drills for all shifts at least twice a year; emergency electrical supply. Includes requirements for administration, patient comfort, and safety, accommodations, equipment and orientation program for emergencies.|
|Michigan||Yes||Emergency generators; administering rules on nursing coverage during emergencies or national disasters. Includes: general provisions for disaster plans, administrative management of policy manual, policies and procedures for care and education and training of unlicensed nursing personnel on safety and fire prevention.|
|Minnesota||Yes||Written disaster plans, including written agreements on securing utilities during disasters; frequency and details on fire drills; evacuation plan. Home must develop and implement an organized safety program in accordance with a written plan including availability of disaster plan and drill requirements.|
|Mississippi||Yes||An Emergency Operations Plan must be developed and maintained to include 6 critical areas: communications; resources & assets; safety & security; staffing; utilities and clinical activities.|
|Missouri||Yes||Nurse assistant training program content. Fire Safety Standards for new and existing facilities requirements. Fire drills and evacuation plan requirements.|
|Montana||Yes||Disaster plan; fire drills specified at low rate of once a year.|
|Nebraska||Yes||Disaster plan specifications (including, moving residents to points of safety in case of fire, tornado, or hazardous materials; obtaining food, water, medicine, medical supplies; if a building is inhabitable to move the patients to a safe location, and in case of an outage - heat, water, cooling, or sewage to provide for the comfort of the patients.|
|Nevada||Yes||Training to new employees and existing employees; unannounced drills; evacuation routes; elaborate written procedures to be followed by the staff and residents in case of disasters.|
|New Hampshire||Yes||Duties & responsibilities to ensure safety, training of personnel, development of program including content requirements of program.|
|New Jersey||Yes||Fire drill frequency (12 fire per year with at least 1 drill per shift, and one drill on a weekend. The local fire department shall participate in at least 1 drill a year with the facility. A disaster planner will be the designated contact with local government agencies and implement disaster or emergency services. Elaborate plans required for evacuation and in-place sheltering. Administrators must be familiar with disaster procedures. Mandatory notification to Department of fires.|
|New Mexico||Yes||Written disaster procedures, which are submitted and approved by local fire authorities. Fire drill frequency. Required to arrange for fire inspections. Fire prevention rules regarding smoking, and environment. Require vehicular access to nursing home at all times with exits and sidewalks and roads free of ice and other obstructions.|
|New York||Yes||Governing body or designated persons to attain or maintain written policies updated annually regarding safety, including fire safety, accident prevention, resident emergency procedures, and facility operation during disruption of service; orientation and training; frequency of fire drills; plans required for resident elopement.|
|North Carolina||Yes||“Detailed, written procedures” required and “unannounced” drills. Emergency procedures for persons on ventilator care. North Carolina rules go very little beyond federal requirements.|
|North Dakota||Yes||Slight additional specification of training requirements and content of emergency plans (e.g. evacuation routes).|
|Ohio||Yes||Written procedures for evacuating all individuals in the nursing home, procedures for ensuring the health and safety of residents during severe weather, or accidents pertaining to airports, trains, and chemical plants. Frequency of drills (12 fire exit drills per year & two disaster preparedness drills, one specifically for a tornado; recording and evaluating the drill; posting a floor plan for locations of fire extinguishers, alarms, fire hoses, exits in each section and on each floor.|
|Oklahoma||Yes||Staff orientation, nursing service in-service, dietary training requirements. Each nursing station will have a copy of the emergency procedures for fire and natural disaster.|
|Oregon||Yes||In-service education and training amount specified. Fire drills will be conducted according to rules of fire marshals and documented. Notification, emergency preparedness plan including required content. Summary of emergency preparedness plan to be submitted to department annually on July 1.|
|Pennsylvania||Yes||Detailed and regularly updated disaster plan required. Fire drills, notification requirements.|
|Rhode Island||Yes||Development of detailed plans for disasters; evacuation routes; frequency of drills; orientation of staff; notification of public health officials if any part of disaster plan is activated; each facility has an MOU with licensing agency and local municipality regarding distribution of medications and/or vaccines in case of a public health outbreak.|
|South Carolina||Yes||Very detailed requirements for evacuation plans and emergency shelter-in-place plans; requirements to receive others during an emergency; emergency; transportation plans; frequency of fire drills; fire prevention policies; emergency generators. Hurricane risks included in State regulation. Includes orientation on emergency preparedness for private sitters. Provisions for a facility to temporarily admit residents in excess of licensed bed capacity during an emergency. Provisions for the use of the facility or services in response to a public health emergency. NFPA fire tests and fire response training.|
|South Dakota||Yes||Frequency of fire drills; training of personnel on fire prevention and emergency preparedness; evacuation plan; reporting of disasters.|
|Tennessee||Yes||Emergency electrical power and generators; disaster plans for exigencies including for fires, earthquakes, toxic fumes, and severe weather; relocation details included in the plan; frequency and details on fire drills and other drills. Life safety requirements, records and reports specifications.|
|Texas||Yes||Registration with Texas Information and Referral Network requirement to assist state in identifying persons needed assistance if an area is evacuated. Very detailed specifications for disaster plan; reporting rules for fires; details on fire/disaster drills; generators and fire extinguishers; other environmental requirements to prevent fires or facilitate fire fighting.|
|Utah||Yes||Written disaster plans; training; required to have methods of communication with local authorities will be established; transportation plans; documentation of resident emergencies and responses; frequency of fire drills; posting of evacuation plan; fire containment procedures; emergency generator.|
|Vermont||Yes||Detailed, annually reviewed plans required that are approved by the Department of Labor and Industry to meet all potential disasters and emergencies. Fire drill frequency. Required reports to licensing agency if a fire occurs.|
|Virginia||Yes||Written plans required and slightly specified for natural disasters or need to relocate residents, including delineating responsibilities; training requirements.|
|Washington||Yes||Written plans, annually renewed, required for the facility to meet potential emergencies and disasters including: fire, severe weather, loss of power, earthquake, explosion, missing resident, loss of water supply, bomb threats, armed individuals, gas leak, loss of heat. Evacuation routes are posted prominently.|
|West Virginia||Yes||Very detailed requirements for disaster planning and evacuation. fire and disaster drill frequency; Records and reports of drills; emergency food supply.|
|Wisconsin||Yes||Each facility shall have a written procedure which shall be followed in case of fire or other disasters, and which shall specify persons to be notified, locations of alarm signals and fire extinguishers, evacuation routes, procedures for evacuating helpless residents, frequency of fire drills, and assignment of specific tasks and responsibilities to the personnel of each shift and each discipline; certification of plans by local fire authorities; fire drill frequency; fire extinguishers and equipment in good repair; physical plant requirements including keeping roads, sidewalks, and exits free of ice and encumbrances.|
|Wyoming||Yes||Requirements for a disaster plan in accordance with Chapter 11, Health Care Emergency Preparedness. Staffing development and additional staffing during an emergency.|