All hazard emergency planning

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LTC Facility Survey Guidance and Provider Attestation Tool

Instructions to Surveyors:
(Please remove this cover page before giving the attestation to the administrator.)
At the Entrance Conference, give the LTC Emergency Preparedness Provider Attestation tool to the Administrator and ask him/her to complete the document and sign the attestation. Instruct the provider to return the document to the Team Coordinator before the end of the survey.
During the survey, observe or otherwise obtain evidence to verify the provider’s compliance with the following elements of an Emergency Preparedness plan:

  • Observe evidence of:

  • Plan was developed with assistance of local and state fire and safety experts1

  • Disaster Feeding plan is written3

  • Plans posted as required:

  • All Hazard Emergency plan posted at nurses’/attendants’ station(s) and other conspicuous locations1

  • Disaster Feeding plan posted in kitchen3

    • Food supplies as required (1 week staples, 48 hours perishables)11

    • Plan to ensure water is available to essential areas when loss of water occurs12, including:

    • Source of emergency water12

      • Storage of emergency water (potable/non-potable)12

    • Method for estimating volume of water required12 (potable/non-potable)(generally 1 gal per person per day)27

  • Confirm through interview:

        • Staff knowledge of generator-powered systems24

        • Staff knowledge of emergency procedures for various situations24, 25

        • Training by local fire department24, 25

        • Staff familiarity with Disaster Feeding Plan3

Attestation'>Cover Page: Instructions for Survey Team


LTC Facility Provider Attestation
Directions: Administrator, Please complete and sign this attestation. Check each item that applies and is included in this facility’s emergency plan. Return the completed signed form to the Survey Team Coordinator by the end of the second day of survey.

Facility Name:




Name of person completing form:




The undersigned representative(s) of the provider hereby attest that, pursuant to the facility’s responsibility to ensure the continuation of essential services at the above-named facility, the provider has developed an All Hazard Emergency Plan that addresses, at a minimum, each of the essential elements described below.




Name and Title (Please print)



The Plan addresses the following elements:

  • General:


    • 123Plan is written,4,7

    • Plan developed with assistance of local & state fire and safety experts1

  • Plan addresses:

  • Building security (access, crowd control, traffic control, etc)

  • Processes & persons to be notified8 (staff, external authorities)

  • Locations of alarm signals8

  • Plan includes a written transfer agreement with one or more hospitals

  • The Emergency/All Hazards Plan is posted at nurses’/attendants’ stations and other conspicuous locations.1,8

  • The Disaster Feeding Plan is posted in the kitchen.

  • Hazards:

  • 456The plan addresses1, procedures for mitigation, preparedness, response and recovery strategies, for each of the following hazards, at a minimum:

  • Fire in the facility

  • Fire in the community

  • Power outage in the facility

  • Power outage – regional

  • Epidemic in facility

  • Epidemic/pandemic in community

  • Hurricane

  • Tornado

  • Earthquake

  • Flooding

  • Heavy snow/blizzard

  • Missing residents4

  • Hazard Vulnerability Analysis (HVA): Facility conducted an HVA to identify emergencies which are potential threats to this specific facility and has developed relevant plans.

  • Sheltering-in-Place and Evacuation:

  • 7Procedure for sheltering residents-in-place

  • 8Evacuation procedures address relocating residents and staff: 7,

  • within the building

  • outside the community

  • outside the facility but within the community

  • Evacuation procedures address:

  • Evacuation routes8

  • Transportation (residents, staff, equipment)

  • Transferring necessities between sites (food, meds, medical records)

  • Tracking residents

  • Inter-facility communications between facility and alternate care site

    • Continuity of Operations Plan (COOP):

  • 9Continuity of Operations Plan (COOP) in place that:

  • Identifies essential functions necessary for facility continuity of operations.

  • Identifies order of succession for each essential function, with each individual’s contact information and:

  • Assigns specific tasks & responsibilities to personnel of each shift8

  • Ensures personnel are trained to perform assigned tasks

  • Specifies delegation of authority for each essential function.

  • Includes “Information Technology” (IT) as essential function.

  • Includes communication plans.

  • Disaster Feeding Plan:

  • 10Facility has a written Disaster Feeding Plan which addresses:

  • Alternate methods for:

  • when equipment is not operable3

  • sanitation of dishes and utensils3

  • hand washing

    • Ability of supplier(s) to meet needs in a regional emergency

  • Cooperation/resource sharing with area facilities/agencies

  • 11Facility has supplies of:

    • staple foods for minimum 1-week period

    • perishable foods for a minimum of 48 hours

  • Water Supply:

    • 12Plan ensures water is available to essential areas when loss of water occurs

    • Plan addresses12:

      • Source of emergency water12

      • Storage of emergency water (potable/non-potable)12

    • Method for estimating volume of water required (potable/non-potable)12 (generally 1 gal per person per day potable)27

    • Ability of supplier(s) to meet needs in a regional emergency

    • Cooperation/resource sharing with area facilities/agencies

      • Essential Medical/Nursing Supplies:

    • 13Oxygen:

    • Plan addresses O2 use/needs during emergency or evacuation and O2 is properly stored on–site.

  • 14Medications:

  • Plan addresses managing medications during an emergency or evacuation, including:

  • Transferring medications during an evacuation

  • Obtaining medications when sheltering-in-place

  • Ability of supplier(s) to meet medication needs in an emergency

  • 15Other Supplies:

  • Resident supplies (incontinent briefs, medical/nursing supplies, etc.)

  • Personal protective equipment (special clothing barriers, gowns, masks, gloves, breathing/respiratory devices, etc.)

  • Reserve supply of linen

  • Environment, Equipment & Supplies:

    • 16Backup Equipment: Plan identifies backup equipment and tools and a system to maintain these in working condition (e.g., flashlights, batteries, (NOAA radios, etc.)

      • 17181920Plan addresses:

  • Management of ventilation system16 in event of emergency that compromises air quality (e.g., fire, chemical cloud, etc.)

    • At least one staff person on each shift trained to shut-down or modify ventilation system if necessary

  • Management of trash, soiled linen and waste material,,

  • Alternative means for hand washing

  • Fire extinguishers and location of alarms8

  • 212223Generator:

  • The plan addresses:

  • systems the generator will power

  • use of emergency outlets in resident rooms and critical common areas

  • generator fuel

  • maintaining system to start in ≤ 10 sec,,

  • Staff know what systems & outlets the generator powers

  • If facility does not have a generator, plan addresses:

  • Illumination in resident rooms/critical common areas

  • Essential backup equipment to be on-hand and maintained in working order in event of power failure (e.g., flashlights, batteries, radio, cell phones, blankets, means to stay warm/cool, etc)16

  • Physical Plant:

    • There is a written preventative maintenance program in effect for maintaining, testing, and inspecting the following physical Plant systems in reliable operating condition16,21,22,23:

  • fire alarm system

  • emergency electrical system (generator)

  • elevators

  • medical gas system

  • portable fire extinguishers

  • battery powered emergency lights (if provided)

  • heating system

  • air conditioning system

  • cooking equipment

  • automatic sprinkler system

  • Training:

  • 2425Personnel trained to perform assigned tasks9:

  • New employees trained in emergency procedures when begin work in facility

  • Emergency procedures periodically reviewed with existing staff24

  • Unannounced, simulated drills using emergency procedures conducted at least twice a year, on all shifts, to test Plan’s effectiveness24,

  • 26At least once a year, employees are instructed by head of local fire department in their duties in case of fire, and training is noted in facility’s records

  • Staff are familiar with the Disaster Feeding Plan3

  • Facility has provided training to assist staff in developing a personal (family) emergency preparedness plan.


1 105 CMR 150.015(E)(1) [R400]: Every facility shall have a written plan and procedures to be followed in case of fire, or other emergency, developed with the assistance of local and state fire and safety experts, and posted at all nurses' and attendants' stations and in conspicuous locations throughout the facility.

2 §483.75(n)] [F519]: ... the facility... must have in effect a written transfer agreement with one or more hospitals...

3 105 CMR 150.009(F)(9)[R265]: All facilities shall plan and post a Disaster Feeding Plan and staff shall be familiar with it. This plan shall include alternate methods and procedures to be used when equipment is not operable, including proper sanitation of dishes and utensils.

4 §483.75(m)(1) [F517]: The facility must have detailed written plans and procedures to meet all potential emergencies and disasters, such as fire, severe weather, and missing residents.

5 Mitigation: “Those activities an organization undertakes in attempting to lessen the severity and impact of a potential emergency”. From: JCAHO 2006 Long Term Care Accreditation Standards for Emergency Management Planning.

6 Preparedness: Those activities an organization undertakes to build capacity and identify resources that may be used if an emergency occurs. From: JCAHO 2006 Long Term Care Accreditation Standards for Emergency Management Planning.

7 NFPA 101 18/ [K48]: There is a written plan for the protection of all patients and for their evacuation in the event of an emergency. (

8 105 CMR 150.015(E)(2)] [R401]: The plan shall specify persons to be notified, locations of alarm signals and fire extinguishers, evacuation routes, procedures for evacuating helpless patients, and assignment of specific tasks and responsibilities to the personnel of each shift.

9 150.015(E)(3) [R402]: All personnel shall be trained to perform assigned task.

10 §483.35(h)(2) [F371]: The facility must store, prepare, distribute, and serve food under sanitary conditions.

11 105 CMR 150.009(F)(5) [R263]: An adequate supply of food of good quality shall be kept on the premises at all times to meet patients’ or residents’ needs. This shall mean supplies of staple foods for a minimum of one-week period and of perishable foods for a minimum of 48 hours.

12 §483.70(h)(1) [F466]: Regulation: The facility must establish procedures to ensure that water is available to essential areas when there is a loss of normal water supply. Guidelines: The facility should have a written protocol which defines the source of water provisions for storing the water, both potable and non-potable, a method for distributing water, and a method for estimating the volume of water required.

13 105 CMR 150.015(D)(11)(e)] [R399]: Oxygen tanks shall be safely stored and labeled when empty.

14 §483.60(a) [F426]: A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

15 105 CMR 150.015(G)(4)(d) [R414]: Adequate supply of clean, ironed or drip dry bed linen, bed rubbers, blankets, bedspreads, washcloths, and towels of good quality and in good condition. This shall mean a supply of linen equal to at least three times the usual occupancy. In facilities that provide Level I or II care, towels and washcloths shall be changed and laundered every day; in facilities that provide Level III and IV care, at least every week and more frequently, if indicated. Bed linen shall be laundered at least weekly and more frequently, if needed.

16 §483.70 [F454]: The facility must be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel and the public.

17 §483.35(h)(3) [F372]: The facility must dispose of garbage and refuse properly.

18 §483.65(c) [F445]: Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

19 105 CMR 150.016(C)(3) [R430]: Wastes and garbage shall be stored and disposed of at proper intervals in a manner to prevent fire hazard, contamination, transmission of disease, a nuisance, a breeding place for flies and insects, or feeding place for rodents.

20 §483.65(b)(3) [F444]: The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice.

21 NFPA 110, 6.3.1: The EPSS shall be maintained to ensure….the system is capable of supplying service within the time specified for the type and…duration specified for the class.

22 105 CMR 150.017(B)(16)(f) An automatic transfer switch shall be installed to transfer to emergency power within ten seconds.

23 §483.70(b)(2) [F455]: An emergency electrical power system must supply power adequate at least for lighting all entrances and exits; equipment to maintain the fire detection, alarm, and extinguishing systems; and life support systems in the event the normal electrical supply is interrupted.... Procedures: Check that the emergency generator starts and transfers power under load conditions with 10 seconds after interruption of normal power.... When life support systems are used, the facility must provide emergency electrical power with an emergency generator (as defined in NFPA 99, Health Care Facilities) that is located on the premises.

24 §483.75(m)(2) [F518]: 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.

25 150.015(E)(4) [R403]: Simulated drills testing the effectiveness of the plan shall be conducted for all shifts at least twice a year.

26 105 CMR 150.015(D)(3)] [R389]: At least once a year, employees of the home shall be instructed by the head of the local fire department or his representative on their duties in case of fire and this noted in the facility's record.

27 42 CFR 483.25(j) hydration (i.e., F327) and interpretative guidelines: “…A general guideline for determining baseline daily fluids needs is to multiply the resident’s body weight in Kg times 30cc (2.2lbs-1kg), except for residents with renal or cardiac distress…” Also see, New England Diet Manual for Extended Care Facilities, Massachusetts Dietetic Association, 2003 pages. 12, 92.

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