U.S. Department of Health and Human Services 
Office of Inspector General 
Nursing Homes Reported  
Wide-Ranging Challenges  
Preparing for Public Health 
Emergencies and Natural 
Disasters 
Ann Maxwell  
Deputy Inspector General 
 for Evaluation and Inspections 
September 2023, OEI-06-22-00100  U.S. Department of Health and Human Services 
 Office of Inspector General 
 
Data in Brief 
 
S  eptember 2023, OEI-06-22-00100 
Nursing Homes Reported Wide-Ranging Challenges Preparing for 
Public Health Emergencies and Natural Disasters 
In June 2022, an estimated 77 percent of nursing homes located in areas 
Key Results 
at greater risk for natural disasters reported experiencing challenges with 
Although most nursing  emergency preparedness activities.  Administrators reported concerns 
homes met Federal  across seven topic areas, with activities related to ensuring proper staffing 
emergency preparedness  during emergencies and transporting residents during evacuations being 
requirements, an estimated  the most problematic.  An estimated 62 percent of nursing homes 
77 percent reported 
reported at least one challenge regarding staffing and an estimated       
challenges with 
50 percent noted at least one challenge regarding transportation.  Other 
preparedness activities 
challenges reported by some nursing homes related to securing beds for 
intended to ensure that 
evacuated residents and planning for infection control and quarantine 
resident care needs are met 
during emergencies. 
during an emergency.  The 
most frequently cited 
We found that even those nursing homes that meet the Federal 
concerns among nursing 
requirements for emergency preparedness face challenges with critical 
homes were ensuring 
aspects of emergency preparedness.  Specifically, we found that only     
proper staffing during 
24 percent of nursing homes in areas at high risk for disasters received a 
emergencies and 
transporting residents  deficiency for not meeting emergency preparedness requirements 
during evacuations.   established by the Centers for Medicare & Medicaid Services (CMS) 
during their most recent compliance surveybut an estimated 77 percent 
of nursing homes reported at least one challenge with preparedness activities.   
We also found that nursing homes reporting challenges had lower community resilience compared to 
other nursing homes, indicating that availability of community resources may be a factor in nursing 
homes experience with preparedness activities.  Further, an estimated one in five nursing homes 
reported difficulties coordinating preparedness activities with multiple community partners. 
Why OIG Did This Review 
OIG has identified emergency preparedness and nursing home safety as priorities.  Nursing home 
failures to adequately plan for and respond to public health emergencies and natural disasters have led 
to tragic results.  Although such outcomes were not typical, they point to the need to identify the 
source of breakdowns and to strengthen nursing home preparedness efforts.   
How OIG Did This Review 
We surveyed a random sample of 199 nursing homes located in geographic areas rated by the Federal 
Emergency Management Agency (FEMA) as having a very high or relatively high risk for natural hazards.  
We received responses from 168 nursing homes and projected the results to all nursing homes in the 
FEMA risk areas.  Respondents rated how challenging each of 49 preparedness activities were for their 
facility.  The activities covered seven topic areas related to emergency preparedness capabilities that are 
important for ensuring safety of residents during emergency events.     RESULTS 
Costly and devastating disasters are increasing in the United States.1  The average 
number of disasters in which damages exceed $1 billion dollars has increased from 
about 7 per year during 20002009 to 20 per year from 20202022.2  These natural 
disasters and other public health emergency events (hereinafter referred to as 
emergencies) often have significant implications for nursing homes, given that 
residents are typically elderly and have medical conditions that make them 
particularly vulnerable during disruptions in care.  Residents and their families rely on 
nursing homes to plan and execute appropriate procedures during emergency events.  
However, prior Office of Inspector General (OIG) work found that although nursing 
homes often met the Centers for Medicare & Medicaid Services (CMS) requirements 
for emergency planning, many failed to follow their own plans or failed to apply 
sufficient efforts.3, 4      
CMS requires nursing homes that participate in the Medicare and Medicaid programs 
to meet a broad range of emergency preparedness requirements.5  The requirements 
include (1) having and maintaining an all-hazards emergency preparedness plan that 
incorporates a facility- and community-based risk assessment, as well as plans for 
continuity of operations; (2) establishing policies and procedures to be followed in the 
event of an emergency; (3) maintaining a communication plan to ensure that affected 
individuals and oversight groups receive needed information; and (4) having a 
program for training staff and conducting exercises to ensure that the plans will be 
effective in the event of an emergency.  State survey agencies survey nursing homes 
on an annual basis to assess compliance with these and other Federal requirements.6   
On the basis of prior OIG work and other 
research, we identified 49 preparedness 
activities intended to ensure that nursing 
homes can meet resident care needs 
during an emergency.  The 49 activities 
are not delineated in CMSs emergency 
preparedness requirements, yet the 
activities are important steps in 
developing nursing home response 
capabilities.  These preparedness 
activities may present challenges to 
nursing homes even when they meet 
CMS requirements.  We divided the  
49 activities across seven topic areas plus 
an other category for activities that did 
not fit into one of the topic areas.   
Data Brief: Nursing Homes Reported Wide-Ranging Challenges Preparing for Public Health Emergencies and Natural Disasters 
OEI-06-22-00100  Results | 2  To identify the prevalence and severity of challenges associated with the 
preparedness activities, we sent a survey to 199 nursing homes in geographic areas 
that are at a significant risk for experiencing a natural hazard.7  In the survey, issued in 
June 2022, we asked nursing home administrators to rate each of the 49 activities in 
terms of how much of a challenge they perceived it to be for their facility.  We 
counted the top two levelsmajor challenge and moderate challenge
collectively as challenges and determined the prevalence of those challenges.  We 
received responses from 168 nursing homes and projected the results to the  
3,097 nursing homes located in areas rated by the Federal Emergency Management 
Agency (FEMA) as having a very high or relatively high risk for natural hazards.  See 
the Methodology on page 15 for a full description of our analyses and the Appendix 
on page 18 for point estimates and 95-percent confidence intervals for all projections. 
Most nursing homes (77 percent) reported challenges when 
preparing for emergencies 
Most nursing homes (an estimated 77 percent) reported that at least one of the 
49 preparedness activities was a major or moderate challenge for their facility.  An 
additional 20 percent of nursing homes reported at least one minor challenge among 
the preparedness activities, meaning that nearly all nursing homes located in areas 
with a very high risk or relatively high risk for natural hazards (an estimated 
96 percent) reported challenges in preparing for emergencies.   
Even those nursing homes that meet the minimum requirements for emergency 
preparedness set out by CMS face challenges with critical aspects of emergency 
preparedness.  Seventy-seven percent of nursing homes reported at least one 
preparedness challenge, but only about a quarter of these nursing homes (24 percent) 
received a deficiency for emergency preparedness in their most recent CMS 
compliance survey.8, 9   
The availability of community resources may factor into how many challenges nursing 
home faces with preparedness activities.  Nursing homes that reported challenges 
were more likely to be located in communities with lower community resilience, as 
measured in FEMAs National Risk Index, compared to other nursing homes.10, 11  
Community resilience is a measure of how well a community can prepare for natural 
hazards, adapt to changing conditions, and recover rapidly from any disruptions.12  
Factors that influence this resilience include home ownership, temporary housing 
availability, access to physicians, high-speed internet infrastructure, flood insurance 
coverage, and local food supplies.13, 14
Data Brief: Nursing Homes Reported Wide-Ranging Challenges Preparing for Public Health Emergencies and Natural Disasters 
OEI-06-22-00100  Results | 3  Nursing homes reported a wide range of challenges with 
emergency preparedness activities, most often related to 
ensuring proper staffing and transporting residents during 
evacuations  
Nursing homes located in areas with a very high risk or relatively high risk for natural 
hazards reported concerns across the seven topic areas, with preparedness activities 
related to staffing during emergencies and transporting residents during evacuations 
being the most problematic.  We estimated that, on average, nursing homes that 
experienced challenges reported having issues with 14 of the 49 preparedness 
activities.  An estimated 62 percent of nursing homes reported at least one challenge 
related to staffing during emergencies and an estimated 50 percent reported at least 
one challenge related to transporting residents during evacuations.  Preparing for the 
use of medical records appeared to be the least problematic, with an estimated 
29 percent of nursing homes reporting a challenge.  (See Exhibit 1.)    
Exhibit 1: Nursing homes cited challenges with ensuring proper staffing 
during emergencies and transporting residents during evacuations most 
frequently.   
Source: OIG analysis of survey data, 2022.  See Table A-1 in the Appendix for confidence intervals. 
Staffing: More than half of nursing homes reported at least one challenge with 
their plans to ensure proper staffing during emergencies.  An estimated 
62 percent of nursing homes reported that at least one staffing activity posed a 
challenge.  The most commonly reported challenges were receiving commitments 
from enough staff to assist with evacuations and mitigating or addressing staff 
burnout in the event of an emergency.  (See Exhibit 2 on the next page for the 
percentage of nursing homes that reported a challenge with each staffing-related 
preparedness activity.)  
Nursing homes explained that some of the challenges associated with emergencies 
were rooted in broader staffing shortages that existed year-round and were 
compounded by the COVID-19 pandemic.  Some nursing homes described ongoing 
Data Brief: Nursing Homes Reported Wide-Ranging Challenges Preparing for Public Health Emergencies and Natural Disasters 
OEI-06-22-00100  Results | 4  difficulties with staffing shortages, such as having 
to rely on external staffing agencies to fill 
We have a staffing plan, but it 
vacancies, which is very expensive.  An 
would be dependent upon the 
administrator in one nursing home reported that 
staff [we have] at the time due to 
75 percent of the facilitys nurses were contracted 
nationwide staffing shortages.   
staff.  Current research has also called attention to 
   Nursing Home Administrator 
staffing shortages in nursing homes and has 
described the problem as pervasive and more 
widespread than in any other health care setting 
(e.g., hospitals).15, 16, 17  These underlying staffing challenges raise concerns about how 
nursing homes will be able to effectively respond to an emergency. 
Exhibit 2: Nursing homes reported challenges with planning for proper 
staffing during emergencies.    
Percentage of 
Staffing Challenges   
Nursing Homes  
Receiving commitments from enough staff to assist with evacuations (e.g., staff to  48% 
travel with residents to evacuation sites) during an emergency 
Mitigating or addressing staff burnout and/or emotional stress during an emergency  48% 
Receiving commitments from enough staff to care for residents when sheltering in  42% 
place during an emergency  
Ensuring that staff can take on expanded responsibilities during an emergency that  35% 
may go beyond their regular duties 
Ensuring adequate space and resources to shelter staff and their families during an  33% 
emergency 
Training new and temporary staff on emergency procedures  28% 
Ensuring that staff can obtain passes that will allow them to move through  20% 
roadblocks to get to the facility during an emergency 
Ensuring staff participation in emergency preparedness activities (e.g., drills, training)  15% 
Nursing homes reporting at least one challenge with staffing  62% 
Source: OIG analysis of survey data, 2022.  See Table A-1 in the Appendix for confidence intervals. 
Transportation: Half of the nursing homes reported at least one challenge with 
establishing agreements with transportation companies.  CMS requires nursing 
homes to have policies and procedures that identify emergency transportation 
services that meet the specific needs of their residents, yet nursing homes have 
repeatedly experienced challenges with transportation companies not meeting their 
commitments during emergency events.18, 19  (See Exhibit 3 on the next page.)  These 
challenges have sometimes resulted in nursing home residents being stranded during 
an emergency because of a lack of available vehicles and vehicles not having 
specialized equipment needed for some residents.20, 21   
Data Brief: Nursing Homes Reported Wide-Ranging Challenges Preparing for Public Health Emergencies and Natural Disasters 
OEI-06-22-00100  Results | 5  An estimated 50 percent of nursing homes 
reported transportation-related challenges.   Transportation is always a major 
The most commonly cited transportation  concern.  We have contracts for bus 
challenge was ensuring that agreements with  service, and pay retainers, but at the 
transportation companies were exclusive so  last hour often the buses are pulled, 
that they would not be double-booked  and we are told they are not 
with other nearby facilities during  available.                 
emergencies.  Nursing homes also reported     Nursing Home Administrator 
concerns about whether transportation 
companies could meet the needs of their 
residents during an emergency (e.g., buses 
equipped to transport bedridden residents).  One nursing home administrator voiced 
the concern that community partners such as local emergency managers did not 
recognize the need to provide special transportation equipment: I do not think that 
most outside agencies understand the difficulty that most skilled nursing patients 
have with ambulation...  
Exhibit 3: Nursing homes reported challenges establishing agreements with 
transportation companies. 
Percentage of 
Transportation Challenges 
Nursing Homes  
Establishing agreements with transportation companies that will be exclusive with  45% 
the facility, to ensure that they are not double-booked with nearby nursing 
homes  
Establishing agreements with transportation companies that meet their potential  41% 
needs during an emergency (e.g., buses equipped to transport bedridden 
residents) 
Finding transportation companies that are affordable  35% 
Ensuring that agreements with transportation companies address potential  35% 
reimbursement or liability concerns that may arise during an evacuation 
Nursing homes reporting at least one challenge with transportation    50% 
Source: OIG analysis of survey data, 2022.  See Table A-1 in the Appendix for confidence intervals. 
The survey results indicate that more than one-third of nursing homes did not have 
agreements with transportation companies to transport residents during emergencies.  
Instead, most of these nursing homes reported that they planned to use their own 
vehicles or rely on residents families for transportation.  The nursing homes without 
transportation agreements were more likely to be located in rural areas, suggesting 
that not having an agreement might be because there are not many (or any) 
transportation companies in those areas.22  Although all nursing homes are within the 
geographic boundaries of a health care coalition (HCC), an estimated 27 percent of 
nursing homes did not participate with their HCC.  The HCCs receive grants from the 
Administration for Strategic Preparedness and Response (ASPR) to improve 
Data Brief: Nursing Homes Reported Wide-Ranging Challenges Preparing for Public Health Emergencies and Natural Disasters 
OEI-06-22-00100  Results | 6  emergency preparedness and response among the health care organizations within 
their boundaries.23  HCCs can assist with resource coordination and management, 
such as identifying transportation companies that can help with evacuations.24  We 
found that nursing homes without transportation agreements were less likely to be 
participating members of an HCC.  Specifically, we found that an estimated 38 percent 
of the nursing homes without transportation agreements were not participating 
members compared to an estimated 20 percent of those with transportation 
agreements.25   
Communication Plan: Nearly half of nursing homes reported at least one 
challenge related to developing and maintaining a comprehensive 
communication plan.  A comprehensive communication plan that includes 
community partners, staff, and family members of residents is critical for ensuring 
continuous care for residents during emergencies.  An estimated 45 percent of 
nursing homes reported difficulty with these plans.  The most cited challenge was 
ensuring that there would be alternative means for communicating during an 
emergency (e.g., satellite phone) in the event of phone/email service disruption (see 
Exhibit 4 on the next page).  Many nursing homes also had problems obtaining 
advanced equipment, such as an automated emergency notification system for 
contacting interested parties (e.g., staff, families, community partners).  Additionally, a 
small percentage of nursing homes reported challenges with maintaining up-to-date 
emergency contact information with community partners.  Nursing homes with these 
emergency contact challenges were more likely to be affiliated with a chain or 
network compared to nursing homes that did not report a challenge.26   
 
 
 
 
 
 
 
 
 
 
Data Brief: Nursing Homes Reported Wide-Ranging Challenges Preparing for Public Health Emergencies and Natural Disasters 
OEI-06-22-00100  Results | 7  Exhibit 4: Nursing homes reported challenges with developing and 
maintaining a communication plan for use in an emergency.  
Percentage of 
Communication Plan Challenges  
Nursing Homes  
Ensuring alternative means for communicating during an emergency (e.g., satellite  32% 
phone) in the event of telephone/email service disruption 
Obtaining an automated emergency notification system to share information with  23% 
interested parties during emergencies (e.g., staff, families, community partners) 
Maintaining clear procedures for communicating with Federal, State, or local  18% 
incident command systems during emergencies 
Maintaining clear procedures for communicating with State or local authorities  16% 
about mandatory evacuations 
Maintaining up-to-date contact information for staff, families, residents, residents  14% 
physicians, or volunteers 
Maintaining up-to-date emergency contact information for community partners  12% 
Keeping emergency chain of command up to date  6% 
Nursing homes reporting at least one challenge with communication plan  45% 
Source: OIG analysis of survey data, 2022.  See Table A-1 in the Appendix for confidence intervals. 
Infection Control: Nearly half of nursing homes reported at least one challenge 
planning for infection control and quarantine during emergencies.  The 
COVID-19 pandemic brought unprecedented infection control challenges for nursing 
homes.  A recent OIG study found that more than 1,300 nursing homes had an 
infection rate of 75 percent or higher during COVID-19 surges in 2020.27  Not 
surprisingly, in this survey, an estimated 44 percent of nursing homes reported 
difficulty developing infection control and quarantine protocols for emergencies.  
More than one-third of nursing homes (an estimated 36 percent) reported challenges 
with preparing to isolate contagious residents during transport or at a receiving 
facility (see Exhibit 5 on the next page).  The next most challenging infection control 
activity was preparing to track resident exposures to contagious infections that occur 
during emergencies.   
 
 
 
 
 
Data Brief: Nursing Homes Reported Wide-Ranging Challenges Preparing for Public Health Emergencies and Natural Disasters 
OEI-06-22-00100  Results | 8  Exhibit 5: Nursing homes reported challenges planning for infection control 
and quarantine during emergencies.  
Percentage of 
Infection Control Challenges  
Nursing Homes  
Isolating contagious patients during transport or at receiving facilities during  36% 
emergencies 
Tracking resident exposures to contagious infections that occur during emergencies   27% 
Maintaining sterile environments to perform patient care and minor procedures  25% 
during emergencies  
Ensuring sufficient stockpiles of supplies to maintain infection control practices  16% 
during emergencies (e.g., personal protective equipment (PPE), disinfectants)   
Screening and testing residents and staff for COVID-19 or other infectious diseases  13% 
during emergencies 
Ensuring that staff are trained and knowledgeable about infection control and  11% 
quarantine protocols during emergencies (e.g., use of PPE)  
Nursing homes reporting at least one challenge with infection control  44% 
Source: OIG analysis of survey data, 2022.  See Table A-1 in the Appendix for confidence intervals. 
Receiving Facilities: More than one-third of nursing homes reported at least one 
challenge with securing locations to evacuate residents and staff.  Some nursing 
homes have struggled to provide adequate care for residents at the receiving facilities 
to which residents and staff are evacuated.  In September 2021, at least five nursing 
home residents in Louisiana died following a botched evacuation for Hurricane Ida, in 
which residents were evacuated to an overcrowded warehouse later deemed unsafe 
and unsanitary.28  Several years earlier in 2005, following Hurricane Katrina, nearly 
6 percent of nursing homes that evacuated had residents who died from causes 
related to the relocation.29 
An estimated 39 percent of nursing homes reported challenges establishing 
agreements with other facilities to temporarily house their residents in the event of an 
evacuation.  The most cited challenge was ensuring that agreements with receiving 
facilities would meet their potential needs during an emergency.  (See Exhibit 6 on the 
next page.)  For example, receiving facilities need to have the capacity to accept the 
number of residents being relocated and have the capability to provide high-acuity 
care in some cases.  Many nursing homes also faced challenges with ensuring 
reimbursement for the care of evacuated residents.  Smaller nursing homes were 
more likely to report certain challenges establishing agreements with receiving 
facilities.  For example, smaller nursing homes had more difficulty finding options for 
receiving facilities located within reasonable driving distances.30  Smaller nursing 
homes also had more challenges ensuring that their agreements would be exclusive 
so that the receiving facility would not accept evacuated residents from other nearby 
nursing homes, which could compromise their ability to meet the needs of the 
evacuated facilities.31  
Data Brief: Nursing Homes Reported Wide-Ranging Challenges Preparing for Public Health Emergencies and Natural Disasters 
OEI-06-22-00100  Results | 9  Exhibit 6: Nursing homes reported challenges with securing locations to 
evacuate residents and staff. 
Percentage of 
Receiving Facilities Challenges  
Nursing Homes  
Ensuring that agreements with receiving facilities meet the nursing homes  29% 
potential needs during an emergency 
Ensuring reimbursement for the care of evacuated residents (e.g., Medicaid  25% 
payments across State lines) 
Ensuring that agreements with receiving facilities will be exclusive to the nursing  23% 
home during an emergency, so they are not double-booked with other nearby 
nursing homes 
Paying for expensive retainer fees at receiving facilities  18% 
Establishing that agreements with multiple facilities to ensure accommodations are  17% 
available for all residents during an evacuation 
Establishing agreements with receiving facilities located within a reasonable driving  17% 
distance 
Nursing homes reporting at least one challenge with receiving facilities  39% 
Source: OIG analysis of survey data, 2022.  See Table A-1 in the Appendix for confidence intervals. 
Collaborative Planning: More than one-third of nursing homes reported at least 
one challenge collaborating with community partners to plan for emergencies.  
A smaller percentage of nursing homes (an estimated 35 percent) reported challenges 
with collaborative planning and raised a number of concerns.  The most common 
challenge was infrequent collaboration on community-wide activities, such as drills.  
(See Exhibit 7 on the next page.)  CMS requires nursing homes to conduct exercises 
twice per year that test their emergency plan, 
including participation in at least one full-scale 
exercise that is community-based.32  When a  Most community partners do not 
community-based exercise is not available,  understand long-term care; 
CMS allows nursing homes to conduct a  therefore, internal emergency 
facility-based exercise to meet this  needs are not recognized when 
requirement.33  Administrators from several  doing community drills.  They are 
nursing homes explained that coordinating  usually for emergency medical 
with community partners for exercises was  services and acute care hospitals.   
difficult and that community partners did not     Nursing Home Administrator 
include their facility or residents in their plan.  
Additionally, some administrators explained 
that their nursing homes lacked the staff and time to adequately build and nurture 
their relationships with community partners. 
Other challenges reported by some administrators included the perception that 
community partners would not prioritize or fully recognize the needs of their facility 
during emergencies.  The types of services that raised the most concern for not being 
Data Brief: Nursing Homes Reported Wide-Ranging Challenges Preparing for Public Health Emergencies and Natural Disasters 
OEI-06-22-00100  Results | 10  prioritized included supplemental staffing and volunteers (reported by an estimated 
20 percent of nursing homes) and restoration of water supply in the event of a 
disruption (reported by an estimated 13 percent of nursing homes).  Nursing homes 
that perceived that their facility would not be prioritized, or their needs would not be 
fully recognized, were more likely to have lower community resilience scores, which 
suggests that their communities are less equipped to prepare for and recover quickly 
from disasters.34, 35   
Exhibit 7: Nursing homes reported challenges with collaborating with 
community partners to plan for emergencies.  
Percentage of 
Collaborative Planning Challenges  
Nursing Homes  
Infrequent collaboration on community-wide emergency preparedness activities  20% 
(e.g., risk assessments) 
Not having adequate internal resources to develop strong collaborative  20% 
relationships with community partners (e.g., staff, time) 
Community partners not including the nursing home in community-based drills  18% 
Community partners not fully recognizing the emergency preparedness needs of  16% 
the nursing home 
Community partners not prioritizing nursing homes during emergencies  16% 
Community emergency preparedness activities not focusing on issues relevant to  12% 
the nursing homes risk assessment 
Nursing homes reporting at least one challenge with collaborative planning  35% 
Source: OIG analysis of survey data, 2022.  See Table A-1 in the Appendix for confidence intervals. 
An estimated one in five nursing homes reported difficulties coordinating 
preparedness activities with multiple community partners.  CMS requires nursing 
homes to have a process for collaborating with a broad range of stakeholders, 
including local health care systems and emergency preparedness officials.36, 37  The 
most frequently cited partners with which nursing homes had difficulty coordinating 
were fire department and/or ambulance followed by local county government and 
local emergency management.  The next most difficult entity to coordinate with, 
according to nursing homes, was an HCC.   
Medical Records: Nearly one-third of nursing homes reported at least one 
challenge related to preparing for use of medical records during emergencies.  
As with collaborative planning, nursing homes reported fewer challenges associated 
with managing medical records.  A prior OIG study found that health care facilities 
struggled to access medical records of evacuated patients during emergencies.38  In 
this survey, 29 percent of nursing homes reported that medical record access was a 
problem.  The most cited challenges were ensuring that last-minute instructions for 
resident care and medication are updated during or just before an emergency, and 
Data Brief: Nursing Homes Reported Wide-Ranging Challenges Preparing for Public Health Emergencies and Natural Disasters 
OEI-06-22-00100  Results | 11  ensuring that electronic health records can be accessed by receiving facilities.  (See 
Exhibit 8.)   
Although fewer nursing homes reported that medical records access was a challenge, 
an estimated 43 percent of nursing homes reported that it would be helpful if the 
Federal government established incentives and legal pathways for sharing medical 
records across health care networks.  Access to resident medical records at evacuation 
sites, including the residents current ailments and a list of medications, is necessary 
for ensuring that residents receive appropriate care during an emergency. 
Exhibit 8: Nursing homes reported challenges preparing for the use of 
medical records during emergencies. 
Percentage of 
Medical Records Challenges  
Nursing Homes  
Ensuring that last-minute instructions for resident care and medication are  17% 
updated during or prior to an emergency 
Ensuring that electronic health records can be accessed by receiving facilities  15% 
Ensuring that medical records are available onsite during a power outage  14% 
Ensuring that medical records are protected and remain confidential during an  12% 
evacuation 
Ensuring that medical records can be transported with residents to the evacuation  10% 
site 
Nursing homes reporting at least one challenge with medical records  29% 
Source: OIG analysis of survey data, 2022.  See Table A-1 in the Appendix for confidence intervals. 
Other Challenges: An estimated 38 percent of nursing homes reported other 
challenges with preparing for emergencies.  We asked nursing homes about 
challenges associated with several preparedness activities that did not fit within the 
seven topic areas.  Although this grouping of activities affected a relatively small 
percentage of nursing homes, they represent additional concerns that should be 
considered in emergency planning.  The most commonly cited challenge among 
these activities was establishing procedures to address physical and mental trauma of 
residents during emergencies.  (See Exhibit 9 on the next page.)  Prior research has 
shown that relocating nursing home residents, such as during evacuations, puts 
residents at risk of negative health outcomes and even death.39  In addition, an 
estimated 15 percent of nursing homes identified prioritizing planning activities in 
accordance with [their] risk assessments as a challenge.   
 
 
 
Data Brief: Nursing Homes Reported Wide-Ranging Challenges Preparing for Public Health Emergencies and Natural Disasters 
OEI-06-22-00100  Results | 12  Exhibit 9: Nursing homes reported other challenges preparing for 
emergencies. 
Percentage of 
Other Challenges  
Nursing Homes  
Establishing procedures to address physical or mental trauma of residents during  23% 
emergencies 
Prioritizing planning activities for addressing the range of emergency events  15% 
identified by the risk assessment 
Dedicating internal resources to emergency planning activities  14% 
Receiving timely reviews and approval of an emergency/evacuation plan to meet  14% 
State or local requirements 
Establishing clear criteria for the decision to evacuate versus shelter in place  13% 
during an emergency 
Developing policies and procedures for tracking the location of residents and staff  10% 
following an evacuation 
Maintaining emergency power systems year-round (e.g., generators)  10% 
Nursing homes reporting at least one other challenge  38% 
Source: OIG analysis of survey data, 2022.  See Table A-1 in the Appendix for point estimates and confidence intervals. 
Data Brief: Nursing Homes Reported Wide-Ranging Challenges Preparing for Public Health Emergencies and Natural Disasters 
OEI-06-22-00100  Results | 13  CONCLUSION  
Natural disasters and public health emergencies, such as the recent COVID-19 
pandemic, have had a profound effect on nursing homes and have underscored the 
need to address the underlying challenges that can hamper emergency preparedness.  
Prior OIG reports found that nursing homes often faced disasters without adequate 
staffing, supplies, and transportation, and with emergency plans that were impractical 
and out of date.40  In September 2021, at least five nursing home residents in 
Louisiana died following a botched evacuation for Hurricane Ida, in which residents 
were evacuated to an overcrowded warehouse later deemed unsafe and unsanitary.41  
A more recent series of OIG reports found that nursing homes faced considerable 
challenges responding to the COVID-19 pandemic, including nearly 1,000 additional 
deaths per day for Medicare beneficiaries during April 2020 compared to April 2019 
owing to the pandemic.42, 43 
The findings in this report align with prior OIG work and highlight the vulnerabilities 
in nursing homes preparedness efforts that may not always be identified during 
CMSs compliance surveys.  We found that the challenges related to ensuring 
appropriate staffing during emergencies and transporting residents during 
evacuations ranked as the most problematic issues for nursing homes.   
Staffing shortages, in particular, have affected nursing home emergency preparedness 
in recent years, and other OIG reports have identified several opportunities for CMS 
to assist nursing homes with staffing challenges.  We believe that CMSs efforts to 
implement these existing OIG recommendations will also help address the emergency 
preparedness concerns we identified.  These recommendations include to (1) re-
examine current nursing staff requirements and revise them as necessary; and 
(2) target nursing homes in most need of infection control intervention, and provide 
enhanced oversight and technical assistance to these facilities as appropriate.44  
Additional efforts to improve staffing in nursing homes, such as those included in the 
White House 2022 plan: Protecting Seniors by Improving Safety and Quality of Care in 
the Nations Nursing Homes, may also be beneficial to improving emergency 
preparedness.  
 
Additionally, many nursing homes reported that they are not participating members 
in their local HCCs, organizations that could assist with coordination of community 
resources such as transportation during an emergency response.  Communities 
depend on many of the same resources during emergencies, and collaborative 
planning could help nursing homes identify potential gaps and issues with their 
emergency plan, such as whether transportation companies are double-booked with 
other facilities.   
Data Brief: Nursing Homes Reported Wide-Ranging Challenges Preparing for Public Health Emergencies and Natural Disasters 
OEI-06-22-00100  Conclusion | 14  METHODOLOGY 
This data brief is based on an electronic survey of nursing home administrators or 
staff responsible for emergency preparedness.  We conducted the survey during 
JuneOctober 2022.  In the survey, we asked nursing homes about a wide range of 
challenges that limit their ability to ensure that resident care needs are met during 
emergencies.  We did not assess nursing homes compliance with Federal emergency 
preparedness requirements or the sufficiency of nursing homes overall emergency 
preparedness.   
In addition to the survey, we used the following data sources: (1) FEMAs National Risk 
Index (NRI); (2) CMSs Certification and Survey Provider Enhanced Reporting (CASPER) 
database; (3) the U.S. Department of Agricultures Rural-Urban Commuting Area 
database; and (4) CMSs Provider Data Catalog. 
Sample 
We used CMSs CASPER database and FEMAs NRI to identify Medicare-certified 
nursing homes with a very high risk or relatively high risk for natural hazards.  CASPER 
provides current data on all Medicare and/or Medicaid certified provider 
organizations in the U.S., totaling more than 15,000 nursing homes.  FEMA created 
the NRI to provide emergency planners and managers at the Federal, State, regional, 
and local levels better information about the relative risk for 18 natural hazards in 
each U.S. County and census tract.45  We selected a random sample of 200 nursing 
homes from the 3,097 Medicare certified nursing homes in census tracts designated 
as a very high risk or relatively high risk according to FEMAs NRI.  One nursing home 
in our sample was no longer in business, which reduced our sample to 199 nursing 
homes.  We received responses from 168 nursing homes for a response rate of 
84 percent.   
Data Collection  
Survey.  The survey consisted largely of closed-ended questions, using Likert scales 
and multiple selection lists (i.e., select all that apply).  The survey also included 
open-ended questions which allowed nursing homes to provide additional details 
about their responses.  Additionally, we asked nursing homes to provide facility-
specific information, such as whether they had experienced an emergency (e.g., 
hurricane, ice storm, tornado) during the past 3 years; whether they were a 
participating member of a health care coalition (HCC); and whether they were part of 
a chain or network.   
We identified 49 activities that can limit nursing homes ability to fully prepare for 
emergencies.  To develop the list, we reviewed prior OIG studies, academic journal 
articles, and news reports.  We also interviewed several nursing home stakeholders, 
Data Brief: Nursing Homes Reported Wide-Ranging Challenges Preparing for Public Health Emergencies and Natural Disasters 
OEI-06-22-00100  Methodology | 15  including a county director of public health emergency preparedness, a nursing home 
advocate, and representatives from an HCC.  We did not seek to assess nursing home 
compliance with CMSs emergency preparedness requirements, nor did we assess the 
sufficiency of nursing homes overall emergency preparedness.  Instead, we focused 
on activities that posed problems for nursing homes in preparing for emergencies.  In 
the survey, we grouped the 49 preparedness activities across 7 topic areas and an 
other category for activities that did not fit into the 7 topic areas.  The seven topic 
areas included transporting residents during an evacuation; ensuring proper staffing; 
securing locations to evacuate residents and staff; infection control and quarantine; 
maintaining a comprehensive communication plan; collaborating with community 
partners; and managing medical records. 
To ensure a high response rate, we contacted nursing homes prior to sending the 
survey to identify the most appropriate respondent, obtain their email address, 
explain the purpose of the survey, and answer any questions they had.  We also sent 
automated reminders and followed up by telephone with the nursing home 
administrators who did not respond.   
Nursing Home and Community Characteristics.  We compared nursing home 
responses regarding the challenges to a variety of facility characteristics.  We 
obtained data about the sampled nursing homes from other sources.  We used CMSs 
CASPER database to identify several nursing home characteristics such as bed count 
and geographic location.  We used the U.S. Department of Agricultures Rural-Urban 
Commuting Area database to identify the percentage of the population in a census 
tract that is rural.   
Nursing home respondents were predominantly mid-size facilities (with an estimated 
74 percent having between 51 and 150 beds).  Most (an estimated 73 percent) were 
participating members of HCCs and more than half (an estimated 61 percent) 
experienced an emergency during the previous 3 years.  The nursing home 
respondents represented both rural and urban areas and over half were part of a 
chain or network. 
Emergency Preparedness Deficiencies.  We captured survey deficiency data from 
CMSs publicly available Provider Data Catalog.  We used the Survey Summary dataset 
from February 2023 to examine the three most recent compliance survey results for 
the 3,097 nursing homes in our sampling frame located in areas that FEMA 
designated as very high risk or relatively high risk for natural hazards.46  The dataset 
did not have the most recent survey results for 32 of the 3,097 nursing homes.   
Analysis   
We analyzed survey responses to identify the prevalence and severity of challenges 
associated with the 49 activities that can facilitate an effective emergency response.  
We asked nursing homes to rate the challenge from the following five options: 
(1) major challenge, (2) moderate challenge, (3) minor challenge, (4) not a challenge, 
and (5) not applicable/not attempted.  We counted only the top two levelsmajor 
Data Brief: Nursing Homes Reported Wide-Ranging Challenges Preparing for Public Health Emergencies and Natural Disasters 
OEI-06-22-00100  Methodology | 16  challenge and moderate challengecollectively as a challenge for determining 
the prevalence of challenges.  This allowed us to focus the analysis on the activities 
that nursing homes perceived to be the most challenging.  Of the 168 nursing homes 
that responded to our survey, 129 reported at least one challenge and, on average, 
they reported having challenges with 14 of the 49 activities.  We projected our sample 
of 168 nursing homes to the 3,097 nursing homes located in areas rated by FEMA as 
having a very high or relatively high risk for experiencing natural hazards.  We 
provided point estimates and 95-percent confidence intervals for all projections (see 
the Appendix).  
We then ranked the seven topics by the percentage of nursing homes that rated any 
activity in that topic area as a challenge.  We also analyzed nursing homes responses 
to the open-ended and multiple selection list survey questions to gain further insights 
into the breadth and severity of challenges.   
We evaluated nursing home characteristics to determine whether nursing homes that 
reported specific challenges in their emergency preparedness efforts shared any 
common characteristics.  For nursing home characteristics with continuous variables 
(e.g., bed count), we performed t-tests to identify statistically significant differences in 
the proportion of nursing homes that reported challenges.  For nursing home 
characteristics with categorical variables (e.g., membership in an HCC), we used 
Fishers Exact tests to determine if there were non-random associations between the 
characteristic and whether the nursing home reported a particular challenge.  (See the 
Appendix for results of statistical tests.) 
Limitations  
This study relies on self-reported data provided by nursing home administrators or 
staff responsible for emergency preparedness.  Many of the survey questions are 
about the respondents perception of how challenging an activity was for their facility.  
The survey responses from these nursing homes cannot be extrapolated to nursing 
homes located outside of these geographic areas.  The findings only pertain to 
nursing homes in geographic locations rated as a very high risk or relatively high risk 
for natural hazards.     
Standards 
We conducted this study in accordance with the Quality Standards for Inspection and 
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency.  
Data Brief: Nursing Homes Reported Wide-Ranging Challenges Preparing for Public Health Emergencies and Natural Disasters 
OEI-06-22-00100  Methodology | 17  APPENDIX 
Appendix: Nursing Home Responses to OIG Survey Questions and 
Associated Comparison Tests 
The tables below provide point estimates and confidence intervals for all projections included in the 
body of the report.  The tables also include p-values for our tests of statistical significance.  
Challenge refers to survey responses that indicated a major challenge or moderate challenge 
and does not include responses that indicated a minor challenge.     
Table A-1: Point estimates and confidence intervals for the percentage of nursing homes that 
reported a challenge with each of the 49 preparedness activities      
Point  95% 
Description  Estimate  Confidence 
(n=168)  Interval 
Staffing Challenges 
Receiving commitments from enough staff to assist with evacuations (e.g., staff to travel with 
48.2%  40.4-56.0% 
residents to evacuation sites) during an emergency 
Mitigating or addressing staff burnout and/or emotional stress during an emergency  47.6%  39.9-55.4% 
Receiving commitments from enough staff to care for residents when sheltering in place during 
42.2%  34.7-50.1% 
an emergency  
Ensuring that staff can take on expanded responsibilities during an emergency that may go 
34.5%  27.4-42.2% 
beyond their regular duties 
Ensuring adequate space and resources to shelter staff and families during an emergency  33.3%  26.3-41.0% 
Training new and temporary staff on emergency procedures  28.0%  21.3-35.4% 
Ensuring that staff can obtain passes that will allow them to move through roadblocks to get to 
20.2%  14.4-27.1% 
the facility during an emergency 
Ensuring staff participation in emergency preparedness activities (e.g., drills, training)  15.5%  10.4-21.9% 
Nursing homes reporting at least one challenge with staffing  61.9%  54.1-69.3% 
Transportation Challenges 
Establishing agreements with transportation companies that will be exclusive with the facility, to  44.6%  37.0-52.5% 
ensure that they are not double-booked with nearby nursing homes  
Establishing agreements with transportation companies that meet their potential needs during  41.1%  33.6-48.9% 
an emergency (e.g., buses equipped to transport bedridden residents) 
Finding transportation companies that are affordable  35.1%  27.9-42.9% 
Ensuring that agreements with transportation companies address potential reimbursement or  35.1%  27.9-42.9% 
liability concerns that may arise during an evacuation 
Nursing homes reporting at least one challenge with transportation   50.0%  42.2-57.8% 
Data Brief: Nursing Homes Reported Wide-Ranging Challenges Preparing for Public Health Emergencies and Natural Disasters 
OEI-06-22-00100  Appendix | 18  Communication Plan Challenges     
Ensuring alternative means for communicating during an emergency (e.g., satellite phone) in  32.1%  25.2-39.8% 
the event of telephone/email service disruption 
Obtaining an automated emergency notification system to share information with interested  23.2%  17.1-30.3% 
parties during emergencies (e.g., staff, families, community partners) 
Maintaining clear procedures for communicating with Federal, State, or local incident command  17.9%  12.4-24.5% 
systems during emergencies 
Maintaining clear procedures for communicating with State or local authorities about  16.1%  10.9-22.5% 
mandatory evacuations 
Maintaining up-to-date contact information for staff, families, residents, residents physicians, or  14.3%  9.4-20.5% 
volunteers 
Maintaining up-to-date emergency contact information for community partners  11.9%  7.4-17.8% 
Keeping emergency chain of command up to date  6.0%  2.9-10.7% 
Nursing homes reporting at least one challenge with communication plan  45.2%  37.6-53.1% 
 
Infection Control Challenges     
Isolating contagious patients during transport or at receiving facilities during emergencies  36.3%  29.0-44.1% 
Tracking resident exposures to contagious infections that occur during emergencies   27.4%  20.8-34.8% 
Maintaining sterile environments to perform patient care and minor procedures during  25.0%  18.7-32.3% 
emergencies  
Ensuring sufficient stockpiles of supplies to maintain infection control practices during  16.1%  10.9-22.5% 
emergencies (e.g., personal protective equipment (PPE), disinfectants)   
Screening and testing residents and staff for COVID-19 or other infectious diseases during  13.1%  8.4-19.2% 
emergencies 
Ensuring that staff are trained and knowledgeable about infection control and quarantine  10.7%  6.5-16.4% 
protocols during emergencies (e.g., use of PPE)  
Nursing homes reporting at least one challenge with infection control  44.1%  36.4-51.9% 
 
Receiving Facilities Challenges     
Ensuring that agreements with receiving facilities meet the nursing homes potential needs  28.6%  21.9-36.0% 
during an emergency 
Ensuring reimbursement for the care of evacuated residents (e.g., Medicaid payments across  25.0%  18.7-32.3% 
State lines) 
Ensuring that agreements with receiving facilities will be exclusive to the nursing home during  23.2%  17.1-30.3% 
an emergency, so they are not double-booked with other nearby nursing homes 
Paying for expensive retainer fees at receiving facilities  18.5%  12.9-25.2% 
Establishing that agreements with multiple facilities to ensure accommodations are available for  17.3%  11.9-23.8% 
all residents during an evacuation 
Establishing agreements with receiving facilities located within a reasonable driving distance  16.7%  11.4-23.2% 
Nursing homes reporting at least one challenge with receiving facilities  39.3%  31.9-47.1% 
 
Data Brief: Nursing Homes Reported Wide-Ranging Challenges Preparing for Public Health Emergencies and Natural Disasters 
OEI-06-22-00100  Appendix | 19  Collaborative Planning Challenges     
Infrequent collaboration on community-wide emergency preparedness activities (e.g., risk  20.2%  14.4-27.1% 
assessments) 
Not having adequate internal resources to develop strong collaborative relationships with  19.6%  13.9-26.5% 
community partners (e.g., staff, time) 
Community partners not including the nursing home in community-based drills  17.9%  12.4-24.5% 
Community partners not fully recognizing the emergency preparedness needs of the nursing  16.1%  10.9-22.5% 
home 
Community partners not prioritizing nursing homes during emergencies  16.1%  10.9-22.5% 
Community emergency preparedness activities not focusing on issues relevant to the nursing  11.9%  7.4-17.8% 
homes risk assessment 
Nursing homes reporting at least one challenge with collaborative planning  35.1%  27.9-42.9% 
 
Medical Records Challenges     
Ensuring that last-minute instructions for resident care and medication are updated during or prior  17.3%  11.9 -23.8% 
to an emergency 
Ensuring that electronic health records can be accessed by receiving facilities  14.9%  9.9-21.2% 
Ensuring that medical records are available onsite during a power outage  13.7%  8.9-19.8% 
Ensuring that medical records are protected and remain confidential during an evacuation  11.9%  7.4-17.8% 
Ensuring that medical records can be transported with residents to the evacuation site  10.1%  6.0-15.7% 
Nursing homes reporting at least one challenge with medical records  29.2%  22.4-36.7% 
 
Other Challenges     
Establishing procedures to address physical or mental trauma of residents during emergencies  23.2%  17.1-30.3% 
Prioritizing planning activities for addressing the range of emergency events identified by the risk  15.5%  10.4-21.9% 
assessment 
Dedicating internal resources to emergency planning activities  14.3%  9.4-20.5% 
Receiving timely reviews and approval of an emergency/evacuation plan to meet State or local  14.3%  9.4-20.5% 
requirements 
Establishing clear criteria for the decision to evacuate versus shelter in place during an emergency  12.5%  7.9-18.5% 
Developing policies and procedures for tracking the location of residents and staff following an  10.1%  6.0-15.7% 
evacuation 
Maintaining emergency power systems year-round (e.g., generators)  10.1%  6.0-15.7% 
Nursing homes reporting at least one other challenge  37.5%  30.2-45.3% 
     
Nursing homes reporting at least one challenge with any of the 49 preparedness activities    
Challenge (major or moderate)  76.8%  69.7-82.9% 
Challenge (major, moderate, or minor)  96.4%  92.4-98.7% 
 
Data Brief: Nursing Homes Reported Wide-Ranging Challenges Preparing for Public Health Emergencies and Natural Disasters 
OEI-06-22-00100  Appendix | 20  Table A-2: Point estimates, confidence intervals, and p-values for comparisons that were 
statistically significant using a t-test  
95% Confidence Interval
Description  Point Estimate  
(p-value) 
Nursing homes that reported any challenge with emergency preparedness were more likely to have lower community 
resilience scores. (n=168) 
Community resilience 
Reported any challenge  54.2  53.854.6 
Did not report a challenge  55.1  54.455.8 
(p=0.0274) 
Nursing homes that did not have an agreement with a transportation company to evacuate residents during an emergency 
were located in more rural areas. (n=168) 
Rural percentage 
Had agreement with transportation company  27.4%  19.9-35.0% 
Did not have agreement with transportation company  44.8%  34.5-55.0% 
(p=0.0075) 
Nursing homes that reported a challenge with finding receiving facilities within a reasonable driving distance were more 
likely to have lower bed counts. (n=168) 
Bed count 
Challenge finding nearby receiving facilities  74.6  58.3-90.8 
Not a challenge finding nearby receiving facilities  101.9  93.4-110.4 
(p=0.0040) 
Nursing homes that reported a challenge ensuring that agreements with receiving facilities would be exclusive, so they are 
not double-booked with other facilities, were more likely to have lower bed counts. (n=168) 
Bed count 
Challenge with agreements  78.3  65.5-91.0 
Not a challenge with agreements  103.1  94.1-112.2 
(p=0.0020) 
Nursing homes that reported a challenge with community partners not prioritizing their facility during emergencies had 
lower community resilience scores. (n=168) 
Community resilience 
Challenge with prioritizing their facility  53.4  52.8-54.1 
Not a challenge with prioritizing their facility  54.9  54.2-55.0 
(p=0.0049) 
Data Brief: Nursing Homes Reported Wide-Ranging Challenges Preparing for Public Health Emergencies and Natural Disasters 
OEI-06-22-00100  Appendix | 21   
Nursing homes that reported a challenge with community partners not fully recognizing their facilitys emergency 
preparedness needs had lower community resilience scores. (n=168) 
    Community resilience   
Challenge with community partners recognizing their needs    53.2  52.5-53.8 
Not a challenge with community partners recognizing their    54.6  54.2-55.0 
needs 
      (p=0.0003) 
 
Table A-3: Point estimates, confidence intervals, and p-values for comparisons that were 
statistically significant using Fishers Exact tests   
95% Confidence Interval  
Description    Point Estimate  
(p-value)* 
Nursing homes without an agreement with a transportation company to evacuate residents during an emergency were less 
likely to be participating members in a health care coalition (HCC). (n=168) 
  Percentage not   
 
member of an HCC  
Had agreement with transportation company    19.6%  12.4-28.7% 
Had no agreement with transportation company    37.9%  26.2-50.7% 
      (p=0.0123) 
Nursing homes that were affiliated with a corporate chain or health care network were more likely to report a challenge 
with maintaining current emergency contact information for community partners. (n=153)** 
  Percentage affiliated   
 
with a chain 
Challenge maintaining contact information    85.0%  62.1-96.8% 
Not a challenge maintaining contact information     59.4%  50.5-67.8%   
      (p= 0.0278) 
*We used a binominal approximation to obtain confidence intervals. 
**We excluded 15 Do not know responses from this analysis. 
 
 
 
 
 
 
 
 
Data Brief: Nursing Homes Reported Wide-Ranging Challenges Preparing for Public Health Emergencies and Natural Disasters 
OEI-06-22-00100  Appendix | 22  Table A-4: Point estimates and confidence intervals for selected nursing home characteristics 
and survey responses not included in the 49 preparedness activities 
 95% Confidence 
Description    Point Estimate  
Interval 
Select Nursing Home Characteristics  
     
Bed count (n=168) 
< 50    15.5%  10.4-21.9% 
50 to 150    74.4%  67.1-80.8% 
> 150    10.1%  6.0-15.7% 
  73.2%  65.9-79.7% 
Participating member in HCC (n=123) 
Experienced emergency in prior 3 years (n=103)  61.3%  53.5-68.7% 
How concerned are you that your facility will not be prioritized for supplemental staffing and volunteers during an 
emergency? (n=168) 
Concerned*     20.2%  14.4-27.1% 
Not concerned    79.8%  72.9-85.6% 
How concerned are you that your facility will not be prioritized for restoration of water supply during an emergency? 
(n=168) 
Concerned*     12.5%  7.9-18.5% 
Not concerned    87.5%  81.5-92.1% 
Do you have an agreement with a transportation company to transport residents during an emergency? (n=168) 
Have an agreement    60.7%  52.9-68.2% 
Do not have an agreement    39.3%  31.9-47.1% 
Can the Federal government better assist your facility in preparing for and responding to an emergency by establishing 
legal pathways for sharing medical records across health care? (n=168) 
Yes    43.5%  35.8-51.3% 
Did not respond    56.6%  48.7-64.2% 
*We did not count nursing homes that reported being a little concerned as concerned for this analysis.   
 
Data Brief: Nursing Homes Reported Wide-Ranging Challenges Preparing for Public Health Emergencies and Natural Disasters 
OEI-06-22-00100  Appendix | 23  ACKNOWLEDGMENTS AND CONTACT 
Acknowledgments 
Ben Gaddis served as the team leader for this study, and Anna Brown served as the 
lead analyst.  Others in the Office of Evaluation and Inspections Dallas Regional Office 
who conducted the study include Demetrius Martinez and Quynh Tran.  Office of 
Evaluation and Inspections headquarters staff who provided support include Joe 
Chiarenzelli, Robert Gibbons, and Sara Swisher.  
This report was prepared under the direction of Ruth Ann Dorrill, Regional Inspector 
General for Evaluation and Inspections in the Dallas Regional Office, and Deputy 
Regional Inspectors General Amy Ashcraft and Petra Nealy. 
Contact 
To obtain additional information concerning this report, contact the Office of Public 
Affairs at Public.Affairs@oig.hhs.gov.  OIG reports and other information can be found 
on the OIG website at oig.hhs.gov. 
Office of Inspector General 
U.S. Department of Health and Human Services 
330 Independence Avenue, SW 
Washington, DC 20201 
Data Brief: Nursing Homes Reported Wide-Ranging Challenges Preparing for Public Health Emergencies and Natural Disasters 
OEI-06-22-00100  Acknowledgments and Contact | 24  ENDNOTES 
1 National Oceanic and Atmospheric Administration, National Centers for Environmental Information, U.S. Billion-Dollar 
Weather and Climate Disasters (2023).  Accessed at Billion-Dollar Weather and Climate Disasters | National Centers for 
Environmental Information (NCEI) (noaa.gov) on April 3, 2023. 
2 Ibid.  
3 OIG, Nursing Home Emergency Preparedness and Response During Recent Hurricanes, OEI-06-06-00020, August 2006. 
4 OIG, Gaps Continue To Exist in Nursing Home Emergency Preparedness and Response During Disasters: 2007-2010, OEI-06-09-
00270, April 2012.  
5 42 CFR  483.73. 
6 Sections 1819(g)(2)(A) and 1919(g)(2)(A) of the Social Security Act; 42 CFR  488.308 and 488.330. 
7 The risk of experiencing a natural hazard was based on FEMAs National Risk Index.  Natural hazards are environmental 
phenomena (e.g., hurricanes, tornadoes) that can negatively impact communities and the environment.  A natural disaster 
occurs when a natural hazard causes widespread damage to a community.  See FEMA, Natural Hazards.  Accessed at 
https://hazards.fema.gov/nri/natural-hazards on March 2, 2022.  
8 The 24-percent figure for nursing homes that received an emergency preparedness deficiency is based on OIGs analysis of 
CMSs Survey Summary of the 3,097 nursing homes from our sampling frame.  Thirty-two nursing homes were missing from 
this analysis.  
9 Prior OIG work identified 1,139 areas of noncompliance with CMS emergency preparedness requirements at 150 nursing 
homes.  OIG, Audits of Nursing Home Life Safety and Emergency Preparedness in Eight States Identified Noncompliance With 
Federal Requirements and Opportunities for the Centers for Medicare & Medicaid Services to Improve Resident, Visitor, and Staff 
Safety, A-02-21-010, July 2022.    
10 Using a t-test, we found a statistically significant difference in the average community resilience scores between nursing 
homes that did not report any challenges and those that did.  This test was conducted with a 95-percent level of confidence 
and yielded a p-value of 0.0253.  See Table A-2 in the Appendix for the point estimate and confidence intervals.       
11 The measure of community resilience is based on FEMAs National Risk Index.  See FEMA, Community Resilience.  Accessed 
at https://hazards.fema.gov/nri/community-resilience on March 30, 2023. 
12 National Institute of Standards and Technology (NIST), Community Resilience, 2020.  Accessed at 
https://www.nist.gov/community-resilience on March 2, 2022. 
13 FEMA, Community Resilience.  Accessed at https://hazards.fema.gov/nri/community-resilience on March 30, 2023. 
14 Hazards Vulnerability & Resilience Institute, Baseline Resilience Indicators for a Community.  Accessed at 
https://www.sc.edu/study/colleges_schools/artsandsciences/centers_and_institutes/hvri/data_and_resources/bric/index.php on 
March 30, 2023. 
15 American Health Care Association and National Center for Assisted Living, Historic Staffing Shortages Continue To Force 
Nursing Homes To Limit New Admissions, Creating Bottlenecks at Hospitals and Reducing Access To Care For Seniors, Press 
Release, July 14, 2022.  Accessed at https://www.ahcancal.org/News-and-Communications/Press-Releases/Pages/Historic-
 
Data Brief: Nursing Homes Reported Wide-Ranging Challenges Preparing for Public Health Emergencies and Natural Disasters 
OEI-06-22-00100  Endnotes | 25   
Staffing-Shortages-Continue-To-Force-Nursing-Homes-To-Limit-New-Admissions,-Creating-Bottlenecks-at-Hospitals-and-
.aspx on January 27, 2023.  
16 American Health Care Association and National Center for Assisted Living, Long Term Care Jobs Report, January 2023.  
Accessed at https://www.ahcancal.org/News-and-Communications/Fact-Sheets/FactSheets/LTC-Jobs-Report-Jan2023.pdf on 
February 2, 2023.   
17 American Health Care Association, State of the Nursing Home Industry: Survey of 524 nursing home providers highlights 
persistent staffing and economic crisis, January 2023.  Accessed at https://www.ahcancal.org/News-and-
Communications/Fact-Sheets/FactSheets/SNF-Survey-December-2022.pdf on February 8, 2023.  
18 42 CFR  483.73(b)(3). 
19 CMS, Updated Guidance for Emergency Preparedness  Appendix Z of the State Operations Manual, March 2021, p. 50.  
Accessed at https://www.cms.gov/files/document/qso-21-15-all.pdf on January 27, 2023. 
20 David Dosa, et al., To Evacuate or Not to Evacuate: Lessons Learned From Louisiana Nursing Home Administrators Following 
Hurricanes Katrina and Rita, Journal of American Medical Directors Association, Vol. 8, Issue 3, March 2007.  Accessed at 
https://www.jamda.com/article/S1525-8610(06)00584-6/fulltext on February 13, 2023.  
21 Gary Blanchard and David Dosa, A Comparison of the Nursing Home Evacuation Experience Between Hurricanes Katrina 
(2005) and Gustav (2008), Journal of American Medical Directors Association, Vol. 10, Issue 9, November 2009.  Accessed at 
https://www.jamda.com/article/S1525-8610(09)00247-3/fulltext on February 13, 2023. 
22 Using a t-test, we found a statistically significant difference in the average percentage of the population that was rural 
between nursing homes with transportation agreements and those without transportation agreements.  This test was 
conducted with a 95-percent level of confidence and yielded a p-value of 0.075.  See Table A-2 in the Appendix for the point 
estimate and confidence intervals.     
23 ASPR, Hospital Preparedness Program (HPP).  Accessed at https://aspr.hhs.gov/HealthCareReadiness/HPP/Pages/default.aspx 
on May 1, 2023. 
24 Ibid. 
25 Using a Fishers Exact test, we found a statistically significant difference between nursing homes that did not have a 
transportation agreement and nursing homes that were not a participating member of an HCC.  This test was conducted with a 
95-percent level of confidence and yielded a p-value of 0.012.  See Table A-3 in the Appendix for the point estimate and 
confidence intervals.    
26 Using a Fishers Exact test, we found a statistically significant difference between nursing homes that reported challenges 
maintaining up-to-date emergency contact information and nursing homes that were part of a chain or network.  This test was 
conducted with a 95-percent level of confidence and yielded a p-value of 0.0278.  See Table A-3 in the Appendix for the point 
estimate and confidence intervals.    
27 The survey process did not identify infection control deficiencies for the majority of the nursing homes with extremely high 
infection rates; this raises questions about how effective the survey process is in preventing and mitigating the spread of 
infectious disease in nursing homes.  OIG, More Than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More 
in the First Year of the COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491, January 
2023.  
28 CNN, Louisiana officials confirm 7 deaths of nursing home residents who were evacuated to hurricane shelter, 
September 4, 2021.  Accessed at https://www.cnn.com/2021/09/04/us/ida-louisiana-nursing-home-deaths-saturday/index.html 
on November 10, 2021. 
 
Data Brief: Nursing Homes Reported Wide-Ranging Challenges Preparing for Public Health Emergencies and Natural Disasters 
OEI-06-22-00100  Endnotes | 26 
  29 Carmen Castro, et al., Surviving the Storms: Emergency Preparedness in Texas Nursing Facilities and Assisted Living 
Facilities, Journal of Gerontological Nursing, Vol. 34, No. 8, 2008.  Accessed at 
https://ltcombudsman.org/uploads/files/issues/surviving-the-storm.pdf on February 14, 2023. 
30 Using a t-test, we found a statistically significant difference in the average bed count between nursing homes that reported 
challenges with establishing agreements with receiving facilities that were located within reasonable driving distances and 
nursing homes that did not report these challenges.  This test was conducted with a 95-percent level of confidence and yielded 
a p-value of 0.0082.  See Table A-2 in the Appendix for the point estimate and confidence intervals.         
31 Using a t-test, we found a statistically significant difference in the average bed count between nursing homes that reported 
challenges with ensuring that their agreements with receiving facilities would be exclusive and nursing homes that did not 
report these challenges.  This test was conducted with a 95-percent level of confidence and yielded a p-value of 0.0064.  See 
Table A-2 in the Appendix for the point estimate and confidence intervals.        
32 42 CFR  483.73(d)(2)(i). 
33 42 CFR  483.73(d)(2)(i)(A). 
34 FEMA, National Risk Index Technical Data, November 2021.  Accessed at 
https://www.fema.gov/sites/default/files/documents/fema_national-risk-index_technical-documentation.pdf on February 14, 
2023. 
35 We conducted two t-tests regarding community resilience.  First, we found a statistically significant difference in the average 
community resilience score between nursing homes that reported challenges with community partners potentially not 
prioritizing their facility and nursing homes that did not report these challenges.  This test was conducted with a 95-percent 
level of confidence and yielded a p-value of 0.0237.  Second, we found a statistically significant difference in the average 
community resilience score between nursing homes that reported challenges with the perception that community partners 
would not fully recognize their facility and nursing homes that did not report these challenges.  This test was conducted with a 
95-percent level of confidence and yielded a p-value of 0.0028.  See Table A-2 in the Appendix for the point estimates and
confidence intervals.
36 CMS, Updated Guidance for Emergency Preparedness  Appendix Z of the State Operations Manual, March 2021, p. 30.  
Accessed at https://www.cms.gov/files/document/qso-21-15-all.pdf on January 28, 2022. 
37 42 CFR  483.73(a)(4) and 483.73(c). 
38 OIG, Hospital Emergency Preparedness and Response During Superstorm Sandy, OEI-06-13-00260, September 2014. 
39 Nicholas Castle and John Engberg, The Health Consequences of Relocation for Nursing Home Residents Following 
Hurricane Katrina, Research on Aging, Vol. 33, Issue 6, November 2011.  Accessed at 
https://journals.sagepub.com/doi/abs/10.1177/0164027511412197 on May 16, 2023. 
40 OIG, Gaps Continue To Exist in Nursing Home Emergency Preparedness and Response During Disasters: 2007-2010, OEI-06-09-
00270, April 2012. 
41 Janet McConnaughey, 15 deaths among nursing home patients moved to warehouse, AP News, September 23, 2021. 
Accessed at https://apnews.com/article/hurricane-ida-health-louisiana-new-orleans-storms-
cf3dae4997b1736e969e19981f473401 on January 27, 2022. 
42 OIG, COVID-19 Had a Devastating Impact on Medicare Beneficiaries in Nursing Homes During 2020, OEI-02-20-00490, 
June 2021. 
43 OIG, More Than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the COVID-19 
Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491, January 2023. 
Data Brief: Nursing Homes Reported Wide-Ranging Challenges Preparing for Public Health Emergencies and Natural Disasters 
OEI-06-22-00100  Endnotes | 27  44 OIG, More Than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the COVID-19 
Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491, January 2023. 
45 FEMA, National Risk Index.  Accessed at https://hazards.fema.gov/nri/map on January 20, 2023. 
46 The Survey Summary dataset includes the three most recent nursing home and fire safety compliance surveys.  The dataset is 
publicly available from CMSs Provider Data Catalog for Nursing Homes Including Rehab Services.  The analysis in this report 
used the Survey Summary dataset from February 2023.  Accessed at https://data.cms.gov/provider-data/dataset/tbry-pc2d on 
July 10, 2023.    
Data Brief: Nursing Homes Reported Wide-Ranging Challenges Preparing for Public Health Emergencies and Natural Disasters 
OEI-06-22-00100  Endnotes | 28