Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
G   C T E
APS  ONTINUE  O  XIST IN 
 
N   H E
URSING  OME  MERGENCY 
 
  P
REPAREDNESS AND 
 
  RESPONSE DURING 
D : 20072010  
ISASTERS     
 
Daniel R. Levinson  
Inspector General 
 
April 2012 
OEI-06-09-00270   
   
EXECUTIVE SUMMARY:  GAPS CONTINUE TO EXIST IN NURSING HOME 
EMERGENCY PREPAREDNESS AND RESPONSE DURING DISASTERS:  
20072010, OEI-06-09-00270 
WHY WE DID THIS STUDY  
Federal regulations require that Medicare- and Medicaid-certified nursing homes have 
written emergency plans and provide employees with emergency preparedness training.  
In a 2006 report about nursing homes that experienced hurricanes, we found that 
emergency plans lacked many provisions recommended by experts.  In response, the 
Centers for Medicare & Medicaid Services (CMS) issued guidance checklists for 
emergency planning of health care facilities, long-term care (LTC) ombudsman 
programs, and State survey agencies (SA).  We conducted this study to assess emergency 
preparedness and response of nursing homes that experienced more recent disasters. 
 
HOW WE DID THIS STUDY 
For this study, we analyzed national survey data to determine compliance with Federal 
regulations.  We also conducted site visits to 24 selected nursing homes that experienced 
floods, hurricanes, and wildfires in 20072010.  We interviewed nursing home 
administrators and staff, local emergency managers, and representatives from State LTC 
ombudsman programs and SAs.  We also compared the emergency plans of each selected 
nursing home to the CMS checklist for health care facilities.   
 
WHAT WE FOUND 
Most nursing homes nationwide met Federal requirements for written emergency plans 
and preparedness training.  However, we identified many of the same gaps in nursing 
home preparedness and response that we found in our 2006 report.  Emergency plans 
lacked relevant informationincluding only about half of the tasks on the CMS 
checklist.  Nursing homes faced challenges with unreliable transportation contracts, lack 
of collaboration with local emergency management, and residents who developed health 
problems.  LTC ombudsmen were often unable to support nursing home residents during 
disasters; most had no contact with residents until after the disasters.  SAs reported 
making some efforts to assist nursing homes during disasters, mostly related to nursing 
home compliance issues and ad hoc needs.  
 
WHAT WE RECOMMEND 
We made three recommendations to CMS and one recommendation to the Administration 
on Aging (AoA).  CMS agreed with our recommendations to revise Federal regulations to 
include specific requirements for emergency plans and training, update the State 
Operations Manual to provide detailed guidance for SAs on nursing home compliance 
with emergency plans and training, and promote use of the checklists.  AoA agreed with 
our recommendation to develop model policies and procedures for LTC ombudsmen to 
protect residents during and after disasters.  Finally, in a memorandum report, we outline 
guidance that CMS can consider when revising the checklist for health care facilities.
   
 
TABLE OF CONTENTS 
 
Objectives ....................................................................................................1 
Background ..................................................................................................1 
Methodology ................................................................................................6 
Findings......................................................................................................10 
In 20092010, 92 percent of nursing homes met Federal      
regulations for emergency plans and 72 percent for emergency 
training, slightly less than the percentages 5 years earlier .............10 
On average, selected nursing homes emergency plans included    
about half of the CMS-recommended checklist tasks, and none          
included all of them ....................................................................... 11 
Administrators from 17 of the 24 selected nursing homes         
reported substantial challenges in responding to disasters ............16 
LTC ombudsmen were often unable to support nursing home 
residents during disasters ...............................................................19 
State survey agencies completed tasks related to nursing home 
compliance and addressed ad hoc facility needs............................20 
Recommendations ......................................................................................22 
Agency Comments and Office of Inspector General Response .....24 
Appendixes ................................................................................................25 
A:  Sample Selection ......................................................................25 
B:  Nursing Home Deficiencies in Emergency Planning and                                     
Training ....................................................................................28 
C:  Centers for Medicare & Medicaid Services-Recommended 
Checklist Tasks ........................................................................30 
D:  Agency Comments ...................................................................34 
Acknowledgments......................................................................................40 
 
   
   
OBJECTIVES 
1.  To determine the nationwide extent of nursing home compliance with 
Federal regulations for emergency preparedness. 
2.  To determine the extent to which selected nursing homes emergency 
plans included tasks recommended by the Centers for Medicare          
& Medicaid Services (CMS) emergency preparedness checklist for 
health care facilities. 
3.  To describe the challenges experienced by selected nursing homes 
during disasters in 20072010. 
4.  To examine the role of selected long-term care (LTC) ombudsman 
programs and State survey agencies (SA) during disasters in        
20072010 and their use of the CMS emergency preparedness 
checklists developed for each entity. 
BACKGROUND 
Nursing home residents and their families rely on facility administrators to 
plan and execute appropriate procedures during disasters.  However, the 
numerous hurricanes during 2004 and 2005 prompted concern about 
nursing home emergency planning, disaster response, and coordination 
between nursing homes and State and local entities.  In a 2006 Office of 
Inspector General (OIG) report, we found that, nationally, 94 percent of 
nursing homes met Federal regulations for emergency plans and              
80 percent met Federal regulations for emergency training in 20042005.1   
However, in a sample of 20 nursing homes, we found that plans often 
lacked information suggested by experts; nursing home administrators and 
staff sometimes did not follow emergency plans during the hurricanes; and 
lack of collaboration between State and local emergency entities and 
nursing homes impeded emergency preparedness and management. 
 After OIG issued the 2006 report, CMS issued guidance regarding the 
emergency planning of health care facilities, including nursing homes.  
This study expands upon the 2006 report to examine the use of CMSs 
guidance by a sample of nursing homes that experienced floods, 
hurricanes, and wildfires during 20072010. 
Federal regulations for nursing home emergency preparedness require that 
Medicare- and Medicaid-certified nursing homes have detailed written 
plans and procedures to meet all potential emergencies and disasters such 
 
1 OIG, Nursing Home Emergency Preparedness and Response During Recent Hurricanes, OEI-06-06-00020, 
August 2006. 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  1 
   
   
as fire, severe weather, and missing residents.  Additionally, Federal 
regulations state that facilities 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.2  According to Federal regulations, certified nursing 
homes must comply with the Life Safety Code (LSC), which requires that 
nursing homes have written copies of a plan for the protection of all 
persons in the event of fire, for their evacuation to areas of refuge, and for 
their evacuation from the building; and that fire drills be conducted 
quarterly on each shift.3  In December 2010, CMS issued an advanced 
notice of proposed rulemaking to establish national emergency 
preparedness requirements for Medicare and Medicaid providers and 
suppliers.4  As of March 2012, CMS had not published the proposed rule 
for comment. 
Verification of Nursing Home Compliance With Federal 
Regulations 
The Omnibus Budget Reconciliation Act of 1987 established a survey and 
certification process for CMS and States to verify that Medicare- and 
Medicaid-certified nursing homes comply with Federal requirements.5  
CMS is responsible for enforcing these requirements.  It enters into 
agreements with SAs to survey each nursing home at least once every     
15 months to certify compliance with Federal requirements, including 
those for emergency preparedness.6  CMS provides guidance to surveyors 
through the State Operations Manual (SOM), which specifies how 
surveyors determine compliance.  When surveyors identify noncompliance 
with Federal requirements, CMS requires nursing homes to submit plans 
of correction and to correct the problems.  If nursing homes do not correct 
the problems, CMS may take enforcement actions, including termination 
of the nursing homes participation in Medicare and Medicaid.7 
 
2 42 CFR  483.75(m). 
3 42 CFR  483.70(a)(i) states that the facility must meet the applicable provisions of the 2000 edition of the 
Life Safety Code of the National Fire Protection Association (NFPA), which is incorporated in the regulation by 
reference.  See NFPA 101 Life Safety Code, 2000 edition,  18.7.1.12 and 19.7.1.12.  Accessed at 
http://www.nfpa.org on May 18, 2011. 
4 Department of Health and Human Services (HHS), Unified Regulatory Agenda (Dec. 20, 2010).  Emergency 
Preparedness Requirements for Medicare Participating Providers and Suppliers (CMS-3178-P).  Accessed at 
http://www.regulations.gov on April 5, 2011. 
5 Omnibus Budget Reconciliation Act of 1987, P.L. 100-203,  4202 and 4212, Social Security Act,  
1819(g) and 1919(g), 42 U.S.C.  1395i3 and 1396r. 
6 42 CFR  488.308(a) and 488.330(a)(1)(i). 
7 42 CFR  488.402(d), 488.408, and 488.456. 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  2 
   
   
Standard survey.  The standard survey includes two assessments of 
emergency preparedness:  emergency planning and emergency training.8  
To determine whether nursing homes meet Federal regulations for 
emergency planning, surveyors are instructed to review emergency plans.9  
Federal regulations state that nursing home emergency plans must include 
procedures to meet all potential emergencies, such as fires, severe weather, 
and missing residents.10  The regulations do not specify required content 
for emergency plans; the SOM indicates only that emergency plans must 
include plans relevant to natural or manmade disasters and include 
procedures for finding a missing resident.11  If surveyors find that 
emergency plans are deficient, they can cite nursing homes with a 
deficiency of Tag F517.12  To determine whether a nursing home meets 
Federal regulations for training in emergency procedures, surveyors are 
instructed to question the nurse in charge and two nursing home staff 
members (e.g., nurse aide, housekeeper, maintenance person) about their 
facilitys emergency plan.13  If the nurse in charge or other staff members 
are unable to answer the questions correctly, the surveyors can cite the 
nursing home with a deficiency of Tag F518.14 
LSC survey.  SAs are also responsible for LSC surveys, which should be 
documented no later than 60 days after conclusion of the standard 
surveys.15  Surveyors must complete additional specialized training to 
conduct the LSC survey, and special consultants, such as fire protection 
engineers or fire alarm technicians, may participate on the survey team.16 
In some cases, SAs may enter into subagreements or contracts with State 
fire authorities to assess LSC compliance.17   
The LSC requires facilities to comply with a set of fire protection 
provisions designed to provide safety from fire, smoke, and panic.18  The 
LSC survey includes two assessments for fire protection:  whether the 
facility has a written plan for the protection and evacuation of all patients 
in an emergency and whether the facility conducts fire drills.  If surveyors 
 
8 CMS, SOM, Pub. No. 100-07, App. PP, Guidance to Surveyors for Long-Term Care Facilities, Tags F517 and 
F518. 
9 Ibid. 
10 42 CFR  483.75(m). 
11 CMS, SOM, App. PP, Tag F323. 
12 CMS, SOM, ch. 2,  2728A. 
13 CMS, SOM, App. PP, Tags 517 and F518. 
14 CMS, SOM, ch. 2,  2728A. 
15 CMS, SOM, ch. 2,  2472C. 
16 CMS, SOM, App. I, Survey Procedures and Interpretive Guidelines for Life Safety Code Surveys, p. 1. 
17 CMS, SOM, ch. 2,  2472B. 
18 CMS, SOM, ch. 2,  2470A. 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  3 
   
   
find that emergency fire plans are deficient, they can cite the nursing 
homes with a deficiency of Tag K48.  Surveyors should also evaluate 
whether nursing homes hold fire drills at unexpected times under varying 
conditions and whether nursing home staff members are familiar with 
emergency procedures.  If fire drill records or staff responses during 
interviews are insufficient, surveyors can cite the nursing homes with a 
deficiency of Tag K50.19 
State LTC Ombudsman Programs 
Federal law requires that each State establish a State LTC ombudsman 
program, funded through the Administration on Aging (AoA), to advocate 
for residents in long-term care facilities, such as nursing homes.20  The 
State LTC ombudsman is responsible for identifying, investigating, and 
resolving complaints made by or on behalf of nursing home residents 
relating to action, inaction, or decisions that may adversely affect the 
health, safety, welfare, or rights of LTC residents.21  The State LTC 
ombudsman also monitors the development and implementation of 
Federal, State, and local laws, regulations, and other governmental 
policies and actions that pertain to the health safety, welfare, and rights of 
LTC residents.22 
Federal law does not explicitly state how LTC ombudsman programs 
should participate in nursing home emergency planning, nor does it 
require that ombudsman programs take specific action during disasters.  
To provide a resource for LTC ombudsmen, AoA partially funded a report 
published in 2000 that describes possible LTC ombudsmen actions during 
nursing home closings and natural disasters.  The report is a collection of 
experiences and perspectives of LTC ombudsmen during disasters, 
describing tasks such as helping to arrange transportation and to find 
facilities with available beds.23     
 
 
 
 
19 CMS, SOM, App. I, Survey Procedures and Interpretive Guidelines for Life Safety Code Surveys, Task 5.  
NFPA, NFPA 101 Life Safety Code, 2000 edition,  18.7.1.12 and 19.7.1.12.  Accessed at 
http://www.nfpa.org  on  May 18, 2011.  Form CMS-2786R (06/2007), Fire Safety Survey Report 2000   
CodeHealth Care. 
20 42 U.S.C.  3058g(a)(1).  AoA, Investments in Change:  Enhancing the Health and Independence of Older 
Adults, 2008 Annual Report, p. 19.   
21 42 U.S.C.  3058g(a)(3)(A). 
22 42 U.S.C.  3058g(a)(3)(G). 
23 S. Murtiashaw, The Role of Long-Term Care Ombudsman in Nursing Home Closures and Natural Disaster, 
2000, National Long-Term Care Ombudsman Resource Center, pp. 4243.  Accessed at 
http://www.ltcombudsman.org on April 23, 2010. 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  4 
   
   
CMS Emergency Preparedness Checklists  
In 2007, CMS published three emergency preparedness checklists as 
recommended tools for health care facilities, SAs, and State LTC 
ombudsman programs: 
  Health care facilities checklist.  This checklist includes 70 tasks, which 
CMS grouped into 23 task categories.  Health care facilities, including 
nursing homes, could implement these tasks to ensure that they have a 
comprehensive emergency plan to respond to any disaster.24  The 
checklist provides guidance for developing emergency plans; ensuring 
adequate supplies of food and water; identifying evacuation routes; 
and transporting patients, critical supplies, and equipment.  It also 
recommends that facilities collaborate with local emergency 
management agencies, suppliers, and providers identified as part of a 
community emergency plan to care for evacuees.   
  State LTC ombudsman program checklist.  This checklist is a resource 
for State LTC ombudsmen and includes such tasks as ensuring that all 
regional and local ombudsmen are familiar with emergency planning 
pertinent to LTC facilities.25 
  State SA checklist.  This checklist encourages collaboration between 
SAs and emergency management agencies and provides guidance on 
the essential functions of SAs during disasters.26 
Disasters in 20072010  
From 2007 to 2010, several disasters substantially affected at least        
210 nursing homes in 7 States, forcing residents to evacuate or shelter in 
place in response to floods, hurricanes, and wildfires.27 
Floods.  In March 2009, flooding of the Red River forced the evacuation 
of six nursing homes in North Dakota.  Across the river in Minnesota, one 
nursing home was evacuated and the residents of another sheltered in 
place.28  In May 2010, widespread flooding along the Mississippi and 
Cumberland Rivers in Tennessee forced the evacuation of at least two 
nursing homes.  Another nursing home evacuated some of its residents, 
and the residents of four others sheltered in place. 
 
24 CMS, Survey & Certification:  Emergency Preparedness Checklist Recommended Tool for Effective Health 
Care Facility Planning.  Accessed at http://www.cms.gov on February 5, 2010. 
25 CMS, Survey & Certification:  Emergency Planning Checklist Recommended Tool For Persons in Long-
Term Care Facilities & Their Family Members, Friends, Personal Caregivers, Guardians & Long-Term Care 
Ombudsman (see Part II).  Accessed at http://www.com.gov on February 5, 2010. 
26 CMS, Survey & Certification:  Emergency Preparedness Checklist Recommended Tool for Effective State 
Agency Planning.  Accessed at http://www.cms.gov on February 5, 2010. 
27 This number is limited to nursing homes affected by the disasters in our study. 
28 This area experienced flooding again in March 2010, although no nursing homes were evacuated. 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  5 
   
   
Hurricanes.  Within a span of 12 days in September 2008, Category 2 
Hurricanes Gustav and Ike made landfall in Cocodrie, Louisiana, and 
Galveston Island, Texas.  Hurricane Gustav forced the evacuation of       
92 nursing homes in the coastal parishes of Louisiana.29  Hurricane Ike, 
the third-costliest hurricane ever to hit the United States, devastated 
Galveston Island and led to a mass evacuation of the Texas gulf coast, 
including 84 nursing homes.30  In September 2010, Category 2 Hurricane 
Earl threatened the Outer Banks of North Carolina, forcing the evacuation 
of three nursing homes; the residents of three others sheltered in place. 
Wildfires.  In October 2007, wildfires threatened heavily populated areas 
near San Diego, California, forcing the evacuation of five nursing homes; 
the residents of three others sheltered in place.  In May 2009, wildfires 
near Santa Barbara, California, forced the evacuation of one nursing 
home, and the residents of four others sheltered in place. 
METHODOLOGY 
Scope  
For this evaluation, we analyzed national CMS survey data to determine 
nursing home compliance with Federal regulations for emergency 
preparedness planning and training in 20092010.  We compared 
emergency plans for 24 selected nursing homes to the CMS emergency 
preparedness checklists and to Federal regulations for emergency 
preparedness planning.  We also interviewed nursing home staff; 
community authorities; State, regional, and local LTC ombudsmen; and 
SA staff to collect information about their experiences during disasters that 
occurred during 20072010.     
Sample  
We purposively selected 24 Medicare- and Medicaid-certified nursing 
homes whose residents sheltered in place or were evacuated in response to 
floods, hurricanes, or wildfires during 20072010.  (See Appendix A for 
details about sample selection, including communities and selected 
nursing home characteristics.)  The 24 nursing homes are within              
16 communities in 13 counties across 7 States.  They received services 
from 11 local and regional LTC ombudsman programs (see Table 1).  
 
 
 
29 According to the Saffir-Simpson Hurricane Wind Scale, a Category 2 hurricane has sustained winds of     
96110 miles per hour.  Winds of this intensity are extremely dangerous and cause extensive damage.  
Accessed at http://www.nhc.noaa.gov on August 30, 2011. 
30 Federal Emergency Management Agency, Hurricane Ike Impact Report, December 8, 2008. 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  6 
   
   
Table 1:  Entities Represented in Selected Sample 
Entity  Number 
Local and Regional Entities   
     Nursing homes  24 
     Communities   16 
     Counties  13 
     Local and regional LTC ombudsman program offices  11 
State Entities   
     State LTC ombudsman programs  7 
     SAs  7 
Source:  OIG analysis of 24 selected nursing homes affected by disasters during 20072010. 
Data Sources and Data Collection   
CMS survey data.  We used CMS Online Survey, Certification, and 
Reporting (OSCAR) data to determine national nursing home compliance 
rates with Federal regulations regarding emergency planning and training 
in 2009 and 2010.31  We obtained the data in March 2011. 
Documentation.  We obtained current (2010) emergency plans and 
supporting documents from each of the 24 selected nursing homes.32  We 
also collected community emergency plans to determine the extent to 
which nursing homes coordinated their plans with the community plans.  
Additionally, we collected materials that regional and local LTC 
ombudsmen used to guide their response to nursing home emergencies.  
We also collected emergency plans and supporting documents from State 
LTC ombudsman programs. 
Onsite interviews.  We conducted structured onsite interviews with nursing 
home administrators, directors of nursing, and other staff involved in the 
disaster response for the 24 selected nursing homes.  We asked 
respondents about their emergency plans and staff training.  We also asked 
about their decisions to evacuate or shelter in place and their experiences 
before, during, and after the disaster. 
We also conducted structured onsite interviews with local emergency 
management officials and LTC ombudsman program staff and volunteers 
in each of the 16 communities where the selected nursing homes are 
located.  (See Table A-3 in Appendix A for the number of interview 
 
31 National statistics include nursing homes from all 50 States, the District of Columbia, Guam, Puerto Rico, 
and the Virgin Islands. 
32 Supporting documents included, but were not limited to, transportation agreements, training for 
transportation vendors and volunteers, records of staff training, exercises and drills, after-action reports, and the 
most recent internal review of the emergency plan. 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  7 
   
   
respondents affiliated with each type of entity.)  We asked respondents 
about their community emergency planning and response, evacuation 
orders, local requirements for nursing homes, assistance provided to 
nursing homes, implementation of plans during the specified disaster, and 
reflections about selected nursing homes disaster responses.  We 
conducted all onsite interviews between July and October 2010. 
Telephone interviews.  We conducted structured telephone interviews with 
officials from SAs and State LTC ombudsman programs for each of the 
seven States where the selected nursing homes are located.  We asked 
respondents about their roles and responsibilities for emergency planning, 
actions taken during the specified disaster, the nature of evacuation orders, 
State nursing home requirements, and assistance provided to nursing 
homes for development and execution of plans.  We also asked SAs about 
training provided to surveyors to prepare them for reviews of nursing 
home emergency plans and training documents.  Additionally, we asked 
whether they used the CMS checklists as tools for emergency planning.  
We conducted all telephone interviews between July and November 2010. 
Data Analysis 
Quantitative analysis.  To determine emergency preparedness compliance 
rates in 20092010, we used standard and LSC survey data to calculate the 
number of deficiencies issued for Tags F517, F518, K48, and K50.  We 
then compared the 20092010 compliance rates with rates found in    
20042005.  Whenever possible, we also quantified interview and 
documentation data. 
Qualitative analysis.  To determine the extent to which selected nursing 
homes emergency plans contained tasks recommended by the CMS 
emergency preparedness checklists, we compared the plans with the        
70 tasks listed in the CMS checklist for health care facilities.  For each 
CMS checklist task, we determined whether the nursing home emergency 
plan contained provisions that matched, partially matched, or did not 
match that CMS task.  Finally, we reviewed the emergency plans to 
determine whether they included procedures for fire, severe storms, and 
missing residents, as stated in Federal regulations.33  For example, if a 
plan did not include procedures for responding to fires, we categorized it 
as a nonmatch for emergency planning for fires. 
To examine the challenges experienced by selected nursing homes during 
disasters in 20072010, we analyzed transcripts from our interviews with 
nursing home administrators, staff, local emergency entities, LTC 
ombudsmen, and SA officials.  Finally, to examine the roles of selected 
 
33 42 CFR  483.75(m). 
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LTC ombudsman programs and SAs during disasters, we analyzed 
transcripts from our interviews with State, local, and regional ombudsmen 
and SA officials.  In analyzing the interview data, we developed themes 
and selected examples to illustrate the respondents experiences. 
Limitations 
This study has two limitations.  First, the purposive sample of 24 selected 
nursing homes is not representative of all nursing homes, nursing home 
emergency plans, or nursing home experiences during disasters.  Second, 
during interviews we relied on respondents recollections of disasters.  
Although this limitation applies to all interviews conducted for the study, 
for 10 of the 24 selected nursing homes, interviews took place 23 years 
after the disasters. 
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency. 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  9 
   
   
FINDINGS 
In 20092010, 92 percent of nursing homes met 
Federal regulations for emergency plans and              
72 percent for emergency training, slightly less than 
the percentages 5 years earlier  
Of the 16,001 nursing homes surveyed nationwide during 2009 and 2010, 
most met Federal regulations.  This is a slight decrease from the 
compliance rates for 2004 and 2005 reported 5 years earlier, when we 
found that 94 percent of nursing homes met Federal regulations for 
planning and 80 percent met regulations for training.34  Although most 
nursing homes met Federal regulations for planning, 28 percent were 
found deficient for inadequately training staff to respond to disasters (see 
Table 2).  Additionally, LSC surveyors cited 20 percent more nursing 
homes for deficiencies in emergency training than surveyors conducting 
standard surveys.  Insufficient planning may be more prevalent than these 
results indicate, however.  According to SA officials we interviewed, 
surveyors primarily focus on resident care issues during standard surveys, 
and therefore may not review emergency plans and training records as 
closely as LSC surveyors might.  Officials from five of the seven States in 
our review reported that they did not train surveyors specifically on 
assessment of nursing home emergency plans.  (See Appendix B for a list 
of nursing home emergency preparedness planning and training 
deficiencies nationally and by State.) 
Table 2:  Nursing Homes Cited for Deficiencies in Emergency Planning and 
Training:  National (20092010) 
Facilities 
Deficiencies  Percentage 
(n=16,001) 
Planning Deficiencies 
     Standard survey (F517)  403  3 
     Life Safety Code (K48)  861  5 
          Total*  1,214  8 
Training Deficiencies 
     Standard survey (F518)  860  5 
     Life Safety Code (K50)  3,936  25 
          Total*  4,466  28 
Source:  OIG analysis of OSCAR data for 20092010. 
 *The totals for planning and training deficiencies are not the sums of the standard survey and LSC 
deficiencies because some facilities had one of each type of deficiency, resulting in some overlap in the 
categories. 
 
34 OIG, Nursing Home Emergency Preparedness and Response During Recent Hurricanes,                
OEI-06-06-00020, August 2006. 
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Among the 24 selected nursing homes, surveyors cited only 3 for planning 
or training deficiencies during their most recent surveys.  For example, 
surveyors cited one nursing home for a planning deficiency resulting from 
insufficient stockpiles of food and a training deficiency for failing to train 
staff to extinguish a kitchen fire.  The remaining two homes were found 
deficient for insufficient documentation of emergency training.  As noted, 
Federal regulations state that nursing home emergency plans must include 
procedures to meet all potential emergencies, such as fires, severe weather, 
and missing residents.35  We found that emergency plans for 12 of the     
24 selected nursing homes lacked procedures for finding missing residents 
and that 1 of these plans also lacked procedures for responding to fires.  
During their most recent standard and LSC surveys, none of these           
12 nursing homes were found deficient for emergency planning.36 
Training for surveyors in five of seven States did not include 
instructions for evaluating emergency plans 
In these five States, SA officials reported that their training for surveyors 
who conduct standard surveys did not include instructions on how to 
evaluate an emergency plan, details for assessing compliance, or training 
specific to planning for disasters in their States.  Officials from the 
remaining two States reported that their surveyor training included 
instructions for assessing nursing home emergency plan compliance with 
Federal regulations.  These instructions included methods for checking 
generators and water supplies and for identifying items typically missing 
from a plan, such as procedures for sheltering in place and planning 
evacuation routes.   
On average, selected nursing homes emergency 
plans included about half of the CMS-recommended 
checklist tasks, and none included all of them 
Most nursing home administrators did not use the recommended CMS 
emergency preparedness checklist for health care facilities in developing 
their emergency plans; and the plans lacked many checklist tasks.  
Administrators from only 13 of the 24 nursing homes were aware of the 
checklist and only 7 of the 13 reported using it in developing their plans.  
Administrators who did not use the checklist explained that they used 
guidance from other sources, such as their corporate offices or local 
emergency managers.  The number of CMS checklist tasks included in the 
24 selected nursing homes plans ranged from 19 to 57 out of 70 tasks (see 
 
35 42 CFR  483.75(m)(1). 
36 Emergency plans submitted to OIG by nursing homes may not have been the same plans reviewed by 
surveyors during the most recent nursing home certification survey. 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  11 
   
   
Table 3).  See Appendix C for a full list of CMS checklist tasks included in 
selected nursing homes emergency plans. 
Table 3:  CMS-Recommended Tasks in Selected Nursing 
Homes Emergency Plans 
Number of CMS-Recommended Tasks   Nursing Home Plans 
(n=70)  With Tasks* (n=24) 
6070   0 
5059   3 
4049  5 
3039   9 
2029   6 
1019   1 
109   0 
     Total  24 
Source:  OIG analysis of 24 selected nursing homes emergency plans in 2010. 
*We credited nursing home emergency plans with containing recommended tasks 
when they matched or partially matched the tasks. 
Emergency plans from selected nursing homes lacked 
checklist tasks within six areas of concern 
In reviewing selected nursing homes emergency plans, we identified six 
areas of particular concern.  These areas represent tasks that nursing 
homes often did not include in their plans but could affect residents during 
disasters:  staffing; resident care; resident identification, information, and 
tracking; sheltering in place; evacuation; and communication and 
collaboration. 
Table 4:  CMS-Recommended Staffing Tasks in Selected 
Nursing Homes Emergency Plans 
Nursing 
Home Plans 
Task 
Without Task 
(n=24)* 
Staffing backup plan  22 
Evacuate staffs family with the facility  19 
Staffing requirements     19 
Shelter staffs family at the facility  14 
Ensure that staff accompany residents during evacuation  12 
Source:  OIG analysis of 24 selected nursing homes emergency plans in 2010. 
*Numbers may not sum to totals shown in Appendix C because of combined task 
categories. 
 
   
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  12 
   
   
Staffing tasks.  Ten of the twenty-four selected nursing homes plans did 
not include any recommended tasks for ensuring sufficient staffing levels 
to provide continuous care for residents during disasters, potentially 
leading to delays in meeting medical and other physical needs.  
Additionally, 22 of 24 plans did not include backup plans for staff unable 
to report to work during the disaster and 19 of 24 plans lacked information 
regarding staffing requirements (see Table 4). 
Resident-care tasks.  Eleven of the twenty-four selected nursing homes 
plans did not include any recommended resident-care tasks.  For example, 
23 of 24 plans did not describe how to handle resident illness or death 
during an evacuation or how to provide disaster counseling to residents.  
As another example, 15 of 24 plans did not contain information regarding 
specific characteristics and needs of residents (see Table 5). 
Table 5:  CMS-Recommended Resident-Care Tasks in 
Selected Nursing Homes Emergency Plans 
Nursing Home 
Task  Plans Without 
Task (n=24)* 
Procedures for resident illness or death en route to 
23 
evacuation site   
Mental health and grief counselors at evacuation site  23 
Resident care during evacuation  17 
Specific characteristics and needs of residents  15 
Source:  OIG analysis of 24 selected nursing homes emergency plans in 2010. 
*Numbers may not sum to totals shown in Appendix C because of combined task 
categories. 
The lack of detailed information about resident-specific needs (e.g., 
nasogastric or enteral feeding tubes, ventilator, and oxygen) and 
characteristics (e.g., Alzheimers and dementia) could pose a threat to the 
well-being of residents by failing to signal the need for special 
transportation and necessary medical care and equipment. 
Resident identification, information, and tracking tasks.  Five of the 
twenty-four selected nursing homes plans did not include any tasks 
related to identifying residents, transferring their information, or tracking 
them.  For example, 7 of the 24 plans did not specify any methods for 
identifying residents (e.g., wristband or nametag), and 11 plans did not 
specify what personal information must accompany residents during an 
evacuation (see Table 6). 
 
 
 
 
 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  13 
   
   
Table 6:  CMS-Recommended Identification, Information, 
and Tracking Tasks in Selected Nursing Homes 
Emergency Plans 
Nursing Home 
Task  Plans Without 
Task (n=24)* 
Method used to identify residents during evacuation  7 
Transfer the following information with each resident:   
Name and contact information for next of kin/power of  19 
attorney 
Date of birth, diagnosis  17 
Current drug/prescription and diet regimens  15 
Name  11 
Method to account for individuals during and after  10 
evacuation 
Source:  OIG analysis of 24 selected nursing homes emergency plans in 2010. 
*Numbers may not sum to totals shown in Appendix C because of combined task 
categories. 
The lack of information about residents prescriptions (e.g., for treatment 
of diabetes) could pose a threat to residents health if essential medications 
are not administered on time to those with chronic conditions. 
Sheltering-in-place tasks.  Twelve of the twenty-four selected nursing 
homes plans did not include any of the recommended tasks for sheltering 
in place.  For example, none of the 24 plans specified the amount of water 
needed to ensure sufficient supply for a minimum of 7 days (see Table 7).   
Table 7:  CMS-Recommended Sheltering-in-Place Tasks in 
Selected Nursing Homes Emergency Plans 
Nursing Home 
Task  Plans Without 
Task (n=24)* 
To care for residents for a minimum 7 days:   
 
Adequate supply of potable water  24 
Extra medical supplies and equipment  22 
Generator fuel supply  19 
Extra pharmacy stocks of common medications  19 
Amounts and types of food in supply  17 
Source:  OIG analysis of 24 selected nursing homes emergency plans in 2010. 
*Numbers may not sum to totals shown in Appendix C because of combined task 
categories. 
Evacuation tasks.  Eleven of the twenty-four selected nursing homes 
plans did not include any recommended tasks regarding evacuation 
procedures.  For example, 22 of 24 plans did not describe how the nursing 
home would transport and protect medical records and medications during 
an evacuation (see Table 8).   
 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  14 
   
   
Table 8:  CMS-Recommended Evacuation Tasks in Selected Nursing 
Homes Emergency Plans 
Nursing Home 
Task  Plans Without 
Task (n=24)* 
Transportation and logistical support of:   
 
Adequate food supply  24 
Water (including amount)  24 
Critical supplies and equipment  19 
Transportation and protection of medications under registered nurse  22 
Transportation and protection of:   
Medical records  22 
Wheelchairs and assistive devices  19 
Evacuation routes:   
Evacuation routes only  15 
Evacuation routes and alternative routes  23 
Source:  OIG analysis of 24 selected nursing homes emergency plans in 2010. 
*Numbers may not sum to totals shown in Appendix C because of combined task categories. 
Communication and collaboration tasks.  Twenty-two of the twenty-four 
selected nursing homes plans lacked tasks for communicating with local 
LTC ombudsmen, residents, and proper authorities during and after a 
disaster (see Table 9). 
Table 9:  CMS-Recommended Communication and Collaboration 
Tasks in Selected Nursing Homes Emergency Plans 
Nursing Home 
Task  Plans Without 
Task (n=24)* 
Communication 
Communicate with and/or notify:   
Local LTC ombudsman program   22 
Residents  15 
Staff  8 
Proper authorities   4 
Resident families  4 
Facility communication infrastructure in the event of telephone failure  7 
Collaboration  
Collaborate with emergency managers to develop plan  16 
Collaborate with emergency managers to determine whether to 
17 
evacuate or shelter in place 
Source:  OIG analysis of 24 selected nursing homes emergency plans in 2010. 
*Numbers may not sum to totals shown in Appendix C because of combined task categories. 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  15 
   
   
Administrators from 17 of the 24 selected nursing 
homes reported substantial challenges in responding 
to disasters 
Administrators and staff from 17 of the 24 selected nursing homes 
reported facing substantial challenges in responding to disasters, whether 
they evacuated or sheltered residents in place.  Of these 17 nursing homes,             
11 were evacuated and 6 sheltered residents in place.  Challenges included 
difficulty following emergency plans as written, logistical problems 
related to transportation and communication, and negative effects of 
evacuation on resident health (see Table 10).  Further, most nursing homes 
that experienced challenges reported that they had not collaborated with 
local emergency management agencies to prepare for disasters. 
Table 10:  Nursing Home Challenges in Responding to Disasters 
Nursing Homes 
Challenge  Reporting  Challenge 
 (n=17)* 
Emergency Plan 
Emergency plan as written:   
Lacked detailed procedural information  9 
Was not specific to disaster experienced  5 
Was missing information or contained inaccurate  information  3 
Staff did not consult plan  2 
Total  12 
Logistics 
Unreliable transportation contracts and agreements  5 
Hospital not available to shelter high-acuity residents  5 
Nursing home resident dispersion  5 
Nursing home residents moved more than once  4 
Inadequate tracking systems for residents and supplies  4 
Closed roads limited access to nursing home  4 
Technological problems with communication devices  3 
Total  13 
Physical and Emotional Effects on Residents 
Some residents experienced:   
Negative effects of evacuation on physical health  9 
Stress, anxiety, fear, or emotional trauma  9 
Total  12 
Source:  OIG analysis of interviews with 24 selected nursing homes administrators and staff in 2010.  
*Nursing homes reporting challenges do not sum to the totals because some reported more than one challenge. 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  16 
   
   
Of the 17 nursing homes that reported challenges, 7 met with local 
emergency managers before the disaster to review the situation, establish 
benchmarks for evacuation, and formulate a response plan.  However, 
most of the 17 nursing homes did not have local emergency managers 
review their emergency plans, and none participated in communitywide 
emergency preparedness exercises and drills before the disaster. 
Nursing home staff struggled to execute emergency plans 
According to administrators from 12 of the 17 nursing homes that reported 
challenges, their emergency plans did not contain accurate or detailed 
information on how to execute their plans and respond to disasters.  For 
example, one administrator of a nursing home that was flooded reported 
that its emergency plan did not include procedures for responding to 
floods, although the nursing home was in a flood plain.  Another 
administrator of a nursing home that was evacuated acknowledged that 
most planning focused on sheltering in place rather than evacuating.  This 
administrator did not have prior agreements with host facilities and found 
that identifying them at the last minute was a formidable task.  
Administrators of two nursing homes reported that they did not consult 
their written emergency plans to prepare for evacuation.  They reported 
piecing together transport by calling upon other nursing homes and local 
emergency entities to evacuate their residents. 
Nursing homes reported logistical problems related to 
transportation and communication 
Administrators from 13 of the 17 nursing homes reported a range of 
logistical problems related to evacuation and sheltering in place.  The most 
common problems, each reported by five nursing homes, were that 
transportation contracts were not honored, hospitals declined to shelter      
high-acuity residents unless their medical conditions warranted admission 
under normal circumstances, and difficulty was experienced in tracking 
residents dispersed to host facilities.  Regarding widespread dispersion, 
residents of 1 home were sent to 20 host facilities, making it difficult for 
staff familiar with the residents to monitor their status and provide care.  
Four nursing homes that were evacuated reported difficulty tracking 
residents and supplies, in some cases temporarily losing residents and 
having difficulty matching displaced residents to personal equipment, such 
as wheelchairs.  Some logistical difficulties were the result of community 
disaster conditions; for example, administrators from four nursing homes 
(as well as LTC ombudsmen) reported that closed roads limited staff 
access and equipment delivery, and administrators from three nursing 
homes reported technical problems using cell phones and walkie-talkies. 
 
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  Nursing homes reported that some residents developed health 
problems, creating challenges in providing care 
Administrators from 12 of the 17 nursing homes reported that some 
residents experienced deteriorating health conditions, skin issues, falls that 
resulted in injury, or death.  Administrators from seven of these nursing 
homes reported that some residents medical conditions deteriorated 
during evacuation, necessitating hospitalization either en route to or 
immediately after their arrival at host facilities.  Administrators from four 
of these nursing homes also reported that an unspecified number of 
residents experienced skin issues, such as bedsores or tears, and 
administrators from two homes reported having a resident who fell, 
resulting in injury at a host facility.  Finally, administrators from 9 of the 
17 nursing homes indicated that some residents experienced emotional 
trauma, such as confusion and anxiety, resulting in at least 1 instance of 
required sedation. 
Most nursing homes that reported challenges did not have 
local emergency managers review their plans, and none 
participated in communitywide emergency exercises and drills 
Of the 17 nursing homes that reported challenges in following their 
emergency plans, 12 were in communities in which local emergency 
management entities did not review and approve their plans.  During 
interviews, emergency managers in these communities expressed 
willingness to review plans but noted that they did not have the authority 
to monitor or verify compliance with the plans.  Moreover, the emergency 
entity reviewing the plan may not be the agency that responds to the 
nursing home during a disaster.  For example, in one county that required 
emergency management review of nursing home plans, the county 
emergency manager reviewed and approved a plan, but the emergency 
manager of the fire department that responded to the nursing homes 
request for assistance did not know of the homes plan.   
Few nursing homes that reported challenges collaborated with local 
emergency managers before the disaster; only 4 of the 17 nursing homes 
reported meeting with them to prepare for specific disasters, 2 participated 
in regular communitywide preparedness meetings, and none participated 
in communitywide exercises and drills.37 
 
37 Since the 2007 wildfires, nursing homes in San Diego County have participated in bed census drills as 
members of their countys nursing home disaster preparedness and response task force.  Skilled Nursing Facility 
Disaster Preparedness Task Force, The San Diego ModelA Skilled Nursing Disaster Preparedness and 
Response Plan, 2009.  Accessed at   http://www.cahfdownload.com/cahf/dpp/SDModel-Final-08-27-09.pdf on 
June 4, 2010. 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  18 
   
   
Six of the 17 nursing homes that experienced challenges were in 
communities in which local emergency managers stated that they perceive 
nursing homes as businesses and therefore responsible for management of 
their own disaster response.  Emergency managers in these communities 
indicated they would assist nursing homes as a last resort, but that they 
had competing priorities for scarce resources.  According to one 
emergency manager, a bus used to evacuate residents from a nursing home 
was originally to be used for indigent and homebound populations. 
LTC ombudsmen were often unable to support 
nursing home residents during disasters 
Local LTC ombudsmen reported that although they have no additional 
emergency-related tasks required by Federal regulation, they continue 
during emergencies to work to ensure resident welfare.  State LTC 
ombudsman programs in four of the seven States had emergency plans to 
ensure continuity of service.  Still, local LTC ombudsmen in all seven 
states were often unable to contact or visit residents of nursing homes 
affected by disasters, potentially affecting resident safety and welfare. 
Although some LTC ombudsmen visited residents of the        
24 selected nursing homes during the disasters, most had no 
contact with them until the disasters ended or residents 
returned to nursing homes 
Administrators from only 3 of the 24 selected nursing homes reported that 
their local LTC ombudsmen visited residents, either while residents were 
in host facilities or immediately upon their return to their nursing homes.  
Ombudsmen from 7 of the 11 local LTC programs reported that areawide 
evacuations, closed roads, and evacuations to distant host facilities 
affected access to residents.  Ombudsmen from 10 of the 11 local LTC 
programs indicated that the disasters likely increased resident 
vulnerabilities.  Ombudsmen said that after reentering facilities, residents 
often talked about difficulties such as emotional trauma and loss of 
privacy. 
Four of the seven State LTC ombudsman programs had 
emergency plans to ensure continuity of service to nursing 
home residents, but none reported using the CMS emergency 
preparedness checklist 
Four of the seven State LTC ombudsman programs had written emergency 
plans to ensure program continuity during disasters.  Officials from three 
of these programs reported they were aware of the CMS emergency 
preparedness checklist for State LTC ombudsman programs, but none 
reported using it to develop plans.  Five of the seven State LTC 
ombudsmen reported that they provided disaster-related information to 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  19 
   
   
regional and local LTC ombudsman programs, including one State LTC 
ombudsman who worked at the State operations command center during 
the disaster.  Three State LTC ombudsmen indicated that they would like 
further clarification of their responsibilities before, during, and after 
disasters. 
State survey agencies completed tasks related to 
nursing home compliance and addressed ad hoc 
facility needs 
SA officials stated that the primary role of the SA was to enforce 
compliance with Federal and State regulations.  However, agency officials 
often accepted additional responsibilities as needs arose, including 
tracking nursing home residents, helping to find placement for evacuated 
residents, and facilitating communication between nursing homes and 
community emergency entities. 
SAs focused primarily on issues related to facility compliance 
with State and Federal regulations 
Officials from the seven SAs indicated that their most important obligation 
related to emergency planning and disaster response was to continue their 
primary task of surveying nursing homes for compliance.  They also 
expressed a responsibility to serve as a conduit between CMS and nursing 
homes, providing information to CMS officials and assisting facilities in 
understanding CMS payment and compliance provisions.  Four of the 
seven SAs completed additional tasks as a result of the disasters that were 
related to facility compliance.  For example, CMS allowed one SA to 
approve temporary waivers for host facilities to exceed their bed capacity 
to accept evacuated residents. 
SAs accepted additional responsibilities as facility needs 
arose, including tracking and assisting with placement of 
residents   
All seven SAs made efforts to assist nursing homes during disasters.  For 
example, officials from four SAs tracked evacuated residents.  In most 
cases, this tracking consisted of manually creating and updating 
spreadsheets.  Officials in one of these States found that before the 
disaster, county emergency managers did not know of all nursing facilities 
in their area.  As a solution, the SA created a facility report listing numbers 
of residents and beds as well as evacuation status.  The SA routinely 
updated and distributed the report to emergency entities.  SAs in three of 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  20 
   
   
  these four States also helped find suitable host facilities.38  Further, 
officials from all SAs reported that they received and answered questions 
from nursing homes.  Common questions included how to discharge 
residents to host facilities and how to obtain State and Federal 
reimbursement for evacuation costs.   
Surveyors in three States identified a need for better planning and 
coordination for returning residents to facilities after disasters.  In two of 
these States, the SAs monitored returns by communicating individually 
with facility administrators and relaying the aggregate information to 
community emergency entities.  In the third State, local emergency 
managers notified the SA that they did not have time to check the 
suitability of nursing homes for reentry.  Instead, SA surveyors visited the 
facilities to determine whether they met standards for returning residents.  
In other cases, SAs positioned themselves as a last resort should nursing 
homes require assistance because of unexpected circumstances, such as 
transportation contracts that were not honored.  State surveyors also 
staffed community shelters as part of their duties as State employees. 
All seven SAs had emergency plans, but none reported using 
the CMS emergency preparedness checklist for SAs 
Officials from the seven SAs explained that as State agencies, their 
emergency plans were integrated into emergency preparedness plans for 
State health departments or for State emergency management agencies.  
Although officials from five of the seven States reported that they were 
aware of the CMS emergency preparedness checklist for SAs, none used it 
as a planning tool.  One SA official indicated that his agency did not use 
the checklist because other State entities are responsible for emergency 
planning and preparedness.  An SA official from another State said that 
CMS guidance regarding disaster management should focus on clarifying 
and communicating CMS policies, rather than on emergency planning 
issues.  This official indicated that payment issues (e.g., the implications to 
the home facility of evacuating residents to a host facility) and instructions 
about what kind of information is required by CMS during disasters may 
not be clear and that it is too difficult in the middle of a crisis to figure 
out the rules. 
 
38 After the disasters, two SAs indicated that they were in the process of purchasing tracking software, and one 
SA now has a system that requires nursing homes to update their resident status twice a day during             
State-declared disasters. 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  21 
   
   
RECOMMENDATIONS 
Five years after the release of the 2006 OIG report highlighting problems 
with nursing home emergency planning and procedures, we identified 
many of the same gaps in nursing home preparedness and response, 
specifically with emergency plans lacking relevant information, unreliable 
transportation contracts, negative effects on residents, and lack of 
collaboration with local emergency management entities.39  Including 
tasks from the CMS emergency preparedness checklist for health care 
facilities is not required, and we found that most plans from selected 
nursing homes lacked many of the tasks recommended in the checklist.  
Though the tasks in the checklist exceed Federal regulatory requirements 
for nursing home emergency plans, their omission could compromise 
resident health and safety and jeopardize effective nursing home response 
to disasters.  To improve nursing home emergency preparedness and 
response to disasters, we recommend that: 
CMS revise Federal regulations by identifying and including in 
its regulations requirements for specific elements of 
emergency plans and training 
Federal regulations require that Medicare- and Medicaid-certified nursing 
homes have detailed written emergency plans and procedures.40  CMS 
should take into account the six areas of concern identified in this report to 
specify elements that should be required for inclusion in nursing home 
plans.  These required elements should apply to all Medicare- and 
Medicaid-certified nursing homes.  Additionally, to enhance the safety and 
welfare of nursing home residents during disasters, CMS should specify 
minimum Federal standards for the frequency and extent of disaster 
response training, exercises, and drills for nursing home staff. 
CMS update the SOM to provide detailed guidance for 
surveyors assessing compliance with Federal regulations for 
nursing home emergency planning and training  
The SOM, which provides CMSs guidance to SAs that assess nursing 
home compliance with Federal regulations, requires that surveyors 
conducting standard surveys review nursing home emergency plans, but 
provides no procedural guidance for how surveyors are to assess plans.41  
CMS should develop detailed and clear guidance for use during surveys to 
ensure more effective assessment of nursing home emergency plans.  CMS 
 
39 OIG, Nursing Home Emergency Preparedness and Response During Recent Hurricanes, OEI-06-06-00020, 
August 2006. 
40 42 CFR  483.75(m). 
41 CMS, SOM, App. PP, Tag 517. 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  22 
   
   
should also provide additional training for surveyors on emergency 
preparedness and plan assessment and standardize when surveyors should 
issue deficiency citations related to emergency planning. 
CMS promote use of the emergency preparedness checklists 
for nursing homes, State LTC ombudsman programs, and SAs  
CMS designed the emergency preparedness checklists as tools for 
effective emergency planning, yet nursing homes, State LTC ombudsman 
programs, and SAs rarely reported using the checklists as guidance.  In 
some cases, officials from these entities were not even aware of the CMS 
checklists.  CMS does not require nursing homes to use the checklists and 
the tasks in the checklist exceed Federal regulatory requirements for 
emergency plans.  Additionally, nursing home administrators indicated 
that they receive emergency planning guidance from other sources.  Still, 
we found that nursing home emergency plans were largely lacking tasks 
recommended in the CMS checklist for health care facilities, which 
provides a comprehensive index of emergency planning tasks. 
Greater use of the checklists could assist nursing homes, State LTC 
ombudsmen programs, and SAs in improving emergency planning and 
disaster management.  CMS should further promote use of the emergency 
preparedness checklists, such as by making additional outreach efforts and 
partnering with AoA, the Office of the Assistant Secretary for 
Preparedness and Response (ASPR), and other emergency preparedness 
entities.  Finally, in a supplemental memorandum report, we outline 
guidance that CMS can consider when revising the checklist for health 
care facilities.42 
AoA develop model policies and procedures to protect 
resident health, safety, welfare, and rights during and after 
disasters 
AoA should collaborate with CMS, ASPR, SAs, and State LTC 
ombudsman programs to identify effective models for State and local LTC 
ombudsman programs during disasters and assist States in their 
development of policies and procedures to protect residents health, safety, 
welfare, and rights during and after disasters.  For example, guidance 
could include potential actions by State and local LTC ombudsmen during 
and after a disaster and identify common problems experienced by 
residents to assist ombudsmen with recognizing and addressing these 
problems.  Additionally, AoA should provide a framework for LTC 
ombudsmens contact with residents after a disaster.  The framework could 
include developing protocols for ombudsmen assigned to a host facility to 
 
42 OIG, Supplemental Information Regarding the Centers for Medicare & Medicaid Services Emergency 
Preparedness Checklist for Health Care Facilities, OEI-06-09-00271, April 2012. 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  23 
   
   
visit displaced residents there.  AoA could also encourage State, local, and 
regional LTC ombudsman programs to develop plans that, to the extent 
possible, ensure that ombudsmen are available to residents whether the 
nursing facility shelters residents in place or is evacuated. 
AGENCY COMMENTS AND OFFICE INSPECTOR GENERAL 
RESPONSE 
We received comments on the draft report from CMS and AoA. 
CMS concurred with each recommendation.   
In response to our recommendation that CMS revise Federal regulations 
by identifying and requiring specific elements of emergency plans and 
training, CMS stated that that it will include specific guidance concerning 
emergency plans and training when it proposes long-term care regulation 
revisions.   
In response to our recommendation that CMS provide detailed guidance 
for surveyors assessing compliance with Federal regulations for 
emergency planning and training, CMS stated that it will update the SOM 
and provide additional training to States and surveyors.  CMS also stated 
that it will issue a policy memorandum for SAs to alert health care 
providers of problems.   
In response to our recommendation that CMS promote use of the 
emergency preparedness checklists, CMS stated that it will work with 
nursing homes, State LTC ombudsman programs, and SAs to reiterate the 
availability of the emergency preparedness materials and encourage their 
use.  CMS also stated that it would review and update the checklists, as 
appropriate. 
AoA concurred with our recommendation to develop model policies and 
procedures to protect residents during disasters.  AoA stated that it is 
collaborating with CMS to update the LTC ombudsmen emergency 
planning checklist and will develop and implement dissemination and 
training strategies.  Additionally, AoA stated that it is collaborating with 
ASPR to promote State LTC ombudsman program awareness and use of 
model policies. 
For the full text of CMS and AoA comments, see Appendix D.  We made 
minor changes to the draft report based on technical comments. 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  24 
   
   
APPENDIX A 
Sample Selection 
Communities.  We identified disaster-affected communities nationwide by 
reviewing information from the Federal Emergency Management Agency 
and State survey agencies (SA).  We focused on disasters that affected 
multiple nursing homes during 20072010, selecting three types of 
disasters for this study:  floods, hurricanes, and wildfires.   
We selected at least two counties in five of the seven States.  For the 
remaining two States (Minnesota and North Dakota), we selected one 
county in each State.  We selected communities for site visits based on 
whether the disaster affected nursing homes within the counties.         
Table A-1 lists information about the communities and disasters associated 
with the selected nursing homes. 
Table A-1:  Community and Disaster Information for Selected Nursing Homes 
Selected Nursing Homes 
(n=24) 
State  County  Population*  Disaster  Year 
Shelter in 
Evacuation 
Place 
County 1  3,053,793  Wildfire  2007  1  2 
CA 
County 2  407,057  Wildfire  2009  2  1 
County 1  109,291  Hurricane  2008  0  1 
LA 
County 2  52,217  Hurricane  2008  1  1 
MN  County 1  56,763  Flood  2009  1  1 
County 1  64,423  Hurricane  2010  2  1 
NC 
County 2  34,296  Hurricane  2010  0  1 
ND  County 1  143,339  Flood  2009  0  2 
County 1  920,232  Flood  2010  0  1 
TN  County 2  26,471  Flood  2010  1  0 
County 3  22,057  Flood  2010  0  1 
County 1  4,070,989  Hurricane  2008  1  1 
TX 
County 1  286,814  Hurricane  2008  1  1 
Total  10  14 
Source: Office of Inspector General (OIG) analysis of nursing homes in selected counties, 2010. 
* Source:  2009 Population Estimates from the U.S. Census Bureau.  Accessed at http://www.census.org on December 20, 
2010.  
 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  25 
   
   
Nursing Homes.  We purposively selected 24 Medicare- and Medicaid-
certified nursing homes based on their diversity in several factors:  disaster 
response (shelter in place or evacuation), size (number of beds), ownership 
(for-profit or nonprofit), and the Centers for Medicare & Medicaid 
Services (CMS) 5-Star Quality of Care rating.  To ensure that we 
interviewed key personnel present during the disaster, we included only 
nursing homes that still employed the administrator and director of nursing 
on duty at the time of the disaster.  Table A-2 lists characteristics of all 
selected nursing homes. 
Table A-2:  Selected Nursing Home Characteristics 
Disaster  CMS 
Facility ID  Size  Ownership  Chain 
Response  Rating 
California 1  Shelter in place  63  Nonprofit  Yes  4 
California 2  Shelter in place  80  Nonprofit  Yes  5 
California 3  Evacuate  156  Nonprofit  Yes  2 
California 4  Evacuate  149  For-profit  No  2 
California 5  Evacuate  90  Nonprofit  Yes  4 
California 6  Shelter in place  59  Nonprofit  Yes  4 
Louisiana 1  Shelter in place  128  For-profit  No  4 
Louisiana 2  Evacuate  124  Nonprofit  Yes  2 
Louisiana 3  Evacuate  198  For-profit  No  1 
Minnesota 1  Evacuate  195  Nonprofit  No  3 
Minnesota 2  Shelter in place  87  For-profit   Yes  3 
North Carolina 1  Shelter in place  92  For-profit   Yes  1 
North Carolina 2  Shelter in place  122  For-profit   No  1 
North Carolina 3  Evacuate  104  For-profit   No  3 
North Carolina 4  Evacuate  126  For-profit   Yes  2 
North Dakota 1  Evacuate  192  Nonprofit  No  3 
North Dakota 2  Evacuate  109  For-profit  Yes  1 
Tennessee 1  Shelter in place  144  For-profit   No  * 
Tennessee 2  Evacuate  119  For-profit   Yes  3 
Tennessee 3  Evacuate  155  For-profit   No  2 
Texas 1  Shelter in place  100  For-profit   No  1 
Texas 2  Evacuate  109  For-profit   Yes  1 
Texas 3  Shelter in place  62  For-profit   Yes  4 
Texas 4  Evacuate  105  Nonprofit  No  5 
Source:  We obtained information about facility size, ownership, chain status, and location from the CMS 
Nursing Home Compare Web site.  Accessed at http://Medicare.gov, MarchJune 2010. 
*CMS rating for this new facility was not available at the time that we selected the nursing homes. 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  26 
   
   
Interview Respondents.  As part of data collection, we interviewed nursing 
home staff from all 24 selected nursing homes; their associated local 
emergency entities; local, regional, and State long-term care (LTC) 
ombudsmen; and SAs.  Table A-3 lists the number of interview 
respondents affiliated with each type of entity. 
Table A-3:  Number of Interview Respondents Affiliated With Each Type of Entity 
State 
Respondent Affiliation 
CA  LA  MN  NC  ND  TN  TX  Total 
Local or Regional Entity 
Nursing home  23  10  6  27  7  28  11  112 
Area agency on aging  0  1  0  1  0  0  0  2 
City emergency management  0  0  0  0  1  0  5  6 
County emergency management  2  2  1  1  1  2  4  13 
County public health department  3  0  3  5  4  1  0  16 
Fire department  0  9  2  3  0  13  0  27 
Local/regional LTC ombudsman  6  4  3  6  1  3  3  26 
program 
Police department  0  1  0  1  0  0  0  2 
Other*  1  0  1  3  1  4  0  10 
State Entity 
State LTC ombudsman program  1  1  1  3  1  1  1  9 
State department of health  4  2  2  1  1  1  0  11 
State survey agency  2  2  3  1  3  2  5  18 
State emergency management agency  0  0  0  1  0  0  0  1 
Other*  0  1  0  0  0  0  0  1 
         Total  42  33  22  53  20  55  29  254 
Source:  OIG analysis of interviews with respondents in the communities and States where selected nursing homes are located, 
2010. 
* Other includes contractors, county commissioners, attorneys, and hospital representatives. 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  27 
   
   
APPENDIX B 
Nursing Home Deficiencies in Emergency Planning and Training 
Table B-1:  Nursing Homes Cited by State Survey Agencies for Deficiencies in Emergency 
Planning and Training by Type of Deficiency:  National and State, 20092010 
Total Number of  Total Emergency  Total Emergency 
National or State  Nursing Homes  Planning Deficiencies  Training Deficiencies 
Surveyed  (Tags F517 and K48)  (Tags F518 and K50) 
   n  Percentage  n  Percentage 
  
National  16,001  1,214  7.6  4,466  27.9 
                 
State               
Alabama  231  23  10.0  57  24.7 
Alaska  15  2  13.3  4  26.7 
Arizona  139  7  5.0  39  28.1 
Arkansas  248  2  0.8  25  10.1 
California  1,251  293  23.4  586  46.8 
Colorado  215  39  18.1  87  40.5 
Connecticut  239  6  2.5  45  18.8 
Delaware  48  0  0.0  16  33.3 
District of  Columbia  19  5  26.3  3  15.8 
Florida  681  34  5.0  81  11.9 
Georgia  360  7  1.9  27  7.5 
Guam  1  1  100.0  0  0.0 
Hawaii  48  1  2.1  8  16.7 
Idaho  80  1  1.3  24  30.0 
Illinois  800  125  15.6  385  48.1 
Indiana  516  38  7.4  193  37.4 
Iowa  456  12  2.6  224  49.1 
Kansas  348  2  0.6  163  46.8 
Kentucky  287  12  4.2  28  9.8 
Louisiana  287  12  4.2  23  8.0 
Maine  109  3  2.8  17  15.6 
Maryland  232  11  4.7  19  8.2 
Massachusetts  433  11  2.5  102  23.6 
Michigan  431  86  20.0  164  38.1 
Minnesota  387  2  0.5  136  35.1 
Mississippi  206  1  0.5  22  10.7 
Missouri  525  29  5.5  241  45.9 
Montana  87  3  3.4  30  34.5 
continued on next page 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  28 
   
   
 
Table B-1:  Nursing Homes Cited by State Survey Agencies for Deficiencies in 
Emergency Planning and Training by Type of Deficiency:  National and State, 20092010 
(Continued) 
Total Number of  Total Emergency  Total Emergency 
 National or State  Nursing Homes  Planning Deficiencies   Training Deficiencies  
Surveyed  (Tags F517 and K48)  (Tags F518 and K50) 
   n  Percentage  n  Percentage 
  
National  16,001  1,214  7.6  4,466  27.9 
                 
State               
Nebraska  232  8  3.4  79  34.1 
Nevada  51  2  3.9  19  37.3 
New Hampshire  80  3  3.8  28  35.0 
New Jersey  362  8  2.2  48  13.3 
New Mexico  74  1  1.4  26  35.1 
New York  640  20  3.1  125  19.5 
North Carolina  429  2  0.5  54  12.6 
North Dakota  87  0  0.0  5  5.7 
Ohio  972  122  12.6  411  42.3 
Oklahoma  336  2  0.6  67  19.9 
Oregon  138  82  59.4  60  43.5 
Pennsylvania  718  19  2.6  110  15.3 
Puerto Rico  7  0  0.0  6  85.7 
Rhode Island  86  0  0.0  6  7.0 
South Carolina  186  3  1.6  9  4.8 
South Dakota  110  0  0.0  32  29.1 
Tennessee  330  7  2.1  79  23.9 
Texas  1,252  73  5.8  282  22.5 
Utah  101  0  0.0  30  29.7 
Vermont  40  0  0.0  3  7.5 
Virgin Islands  1  0  0.0  1  100.0 
Virginia  291  9  3.1  24  8.2 
Washington  235  20  8.5  74  31.5 
West Virginia  127  0  0.0  10  7.9 
Wisconsin  398  63  15.8  107  26.9 
Wyoming  39  2  5.1  22  56.4 
Source:  Office of Inspector General analysis of the Centers for Medicare & Medicaid Services Online Survey, Certification, and 
Reporting data for 20092010. 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  29 
   
   
APPENDIX C 
Centers for Medicare & Medicaid Services-Recommended Checklist Tasks 
Table C-1:  Centers for Medicare & Medicaid Services-Recommended Checklist Tasks Included in 24 
Selected Nursing Homes Emergency Plans 
Nursing Home Plans 
  With Tasks (n=24)* 
Tasks (n=70)  
M  PM  NM 
1.  Develop Emergency Plan:  Gather all available information when developing the emergency plan.     
This information includes, but is not limited to: 
 
1a.  Copies of any state and local emergency planning regulations or requirements.  4  1  19 
1b.  Facility personnel names and contact information.  11  12  1 
1c.  Contact information of local and state emergency managers.  1  17  6 
 
1d.  A facility organization chart.  15  0  9 
1e.  Building construction and Life Safety systems information.  6  16  2 
1f.   Specific information about the characteristics and needs of individuals for whom care is provided.   9  0  15 
2.  All-Hazards Continuity of Operations (COOP) Plan:  Develop a continuity of operations business plan 
using an all-hazards approach (e.g., hurricanes, floods, tornadoes, fire, bioterrorism, pandemic, etc.) 
that could potentially affect the facility directly and indirectly within the particular area of location.   1  23  0 
Indirect hazards could affect the community but the not the facility and as a result interrupt necessary 
utilities, supplies or staffing.  Determine all essential functions and critical personnel.   
3.  Collaborate with Local Emergency Management Agency:  Collaborate with local emergency 
8  0  16 
management agencies to ensure the development of an effective emergency plan.  
4.  Analyze Each Hazard: Analyze the specific vulnerabilities of the facility and determine the    
following actions for each identified hazard. 
 
4a.  Specific actions to be taken for the hazard.  22  0  2 
4b.  Identified key staff responsible for executing plan.  24  0  0 
4c.  Staffing requirements and defined staff responsibilities.   4  20  0 
4d.  Identification and maintenance of sufficient supplies and equipment to sustain operations and 
 
deliver care and services for 3-10 days, based on each facilitys assessment of its hazard  2  17  5 
vulnerabilities.  
4e.  Communication procedures to receive emergency warning/alerts, and for communication with 
4  19  1 
staff, families, individuals receiving care, before, during and after the emergency.  
 4f.  Designate critical staff, providing for other staff and volunteer coverage and meeting staff needs, 
1  13  10 
including transportation and sheltering critical staff members family. 
5.  Collaborate with Suppliers/Providers:  Collaborate with suppliers and/or providers who have been 
identified as part of a community emergency plan or agreement with the health care facility to receive 
and care for individuals.  A surge capability assessment should be included in the development of the 
0  15  9 
emergency plan.  Similarly, evidence of a surge capacity assessment should be included if the supplier 
or provider, as part of its emergency planning, anticipates the need to make housing and sustenance 
provisions for the staff or the family of staff. 
6.  Decision Criteria for Executing Plan:  Include factors to consider when deciding to evacuate or shelter 
in place.  Determine who at the facility level will be in authority to make the decision to execute the plan 
3  20  1 
to evacuate or shelter in place (even if no outside evacuation order is given) and what will be the chain 
of command.   
7.  Communication Infrastructure Contingency:  Establish contingencies for the facility communication 
infrastructure in the event of telephone failures (e.g., walkie-talkies, ham radios, text messaging  17  0  7 
systems, etc.) 
*We coded plans as a match (M) if they included all parts of a task, a partial match (PM) if they included at least one part of a task (e.g., listing the 
person responsible for carrying out a task, but not describing how the task would be performed), and a nonmatch (NM) if they lacked all parts of a task.  
The highest number in each category is in bold font. 
continued on next page 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  30 
   
   
Table C-1:  Centers for Medicare & Medicaid Services-Recommended Checklist Tasks Included in 24 
Selected Nursing Homes Emergency Plans (Continued) 
Nursing Home Plans 
Tasks (n=70)  With Tasks (n=24) 
M  PM  NM 
8.  Develop Shelter in Place Plan: Due to the risks in transporting vulnerable patients and residents,   
evacuation should only be undertaken if sheltering-in-place results in greater risk.  Develop an effective  
plan for sheltering-in-place, by ensuring provisions for the following are specified:   
  8a.  Procedures to assess whether the facility is strong enough to withstand strong winds, floods,   
0  4  2 
etc.    
8b.  Measures to secure the building against damage (plywood for windows, sandbags and plastic    2
0  4 
for flooding), safest areas of the facility are identified.    
8c.  Procedures for collaborating with local emergency management agency, fire, police and EMS  1
7  0 
agencies regarding the decision to shelter-in-place.    
8d.  Sufficient resources are in supply for sheltering-in-place for at least 7 days, including: 
8d1.  Ensuring emergency power, including back-up generators and accounts for maintaining  a 
0  15  9 
supply  of fuel. 
8d2.  An adequate supply of potable water (recommended amounts vary by population and 
0  11  13 
location). 
  8d3.  A description of the amounts and types of food in supply.  7  7  10 
  8d4.  Maintaining extra pharmacy stocks of common medications.  5  0  19 
  8d5.  Maintaining extra medical supplies and equipment (e.g., oxygen, linens, vital equipment).  2  4  18 
  8e.  Identifying and assigning staff who are responsible for each task.  19  4  1 
  8f.  Description of hosting procedures, with details ensuring 24-hour operations for minimum of 7 
0  6  18 
days. 
  8g.  Contract established with multiple vendors for supplies and transportation.  13  5  6 
  8h.  Develop a plan for addressing emergency financial needs and providing security.  2  8  14 
9.  Develop Evacuation Plan:  Develop an effective plan for evacuation, by ensuring provisions for    
the following are specified: 
  9a.  Identification of person responsible for implementing the facility evacuation plan (even if no   
22  0  2 
outside evacuation order is given). 
9b.  Multiple pre-determined evacuation locations (contract or agreement) with a like facility have 
been established, with suitable space, utilities, security and sanitary facilities for individuals 
15  4  5 
receiving care, staff and others using the location.  A back-up may be necessary if the first one is 
unable to accept evacuees. 
9c.  At least one pre-determined evacuation location is 50 miles away.  12  0  12 
9d.  Evacuation routes and alternative routes have been identified, and the proper authorities have 
0  21  3 
been notified.  Maps are available and specified travel time has been established. 
9e.  Adequate food supply and logistical support for transporting food is described.  0  9  15 
9f.  The amount of water to be transported and logistical support is described.  0  6  18 
9g. The logistics to transport medications is described, including ensuring their protection under the 
2  17  5 
control of a registered nurse. 
9h.  Procedures for protecting and transporting resident/patient medical records.  2  19  3 
  9i.  The list of items to accompany residents/patients is described.  8  0  16 
  9j.  Identify how persons receiving care, their families, staff and others will be notified of the 
4  18  2 
evacuation and communication methods that will be used during and after the evacuation. 
 
 
continued on next page 
 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  31 
   
   
Table C-1:  Centers for Medicare & Medicaid Services-Recommended Checklist Tasks Included in 24 
Selected Nursing Homes Emergency Plans (Continued) 
Nursing Home Plans 
With Tasks (n=24) 
Tasks (n=70) 
M  PM  NM 
9.  Develop Evacuation Plan (Continued):  Develop an effective plan for evacuation, by ensuring provisions 
 
for the following are specified: 
  9k.  Identify staff responsibilities and how individuals will be cared for during evacuation, and the 
1  17  6 
back-up plan if there isnt sufficient staff. 
9l.   Procedures are described to ensure residents/patients dependent on wheelchairs and/or 
assistive devices are transported so their equipment will be protected and their personal needs 
3  5  16 
met during transit (e.g., incontinent supplies for long periods, transfer boards and other assistive 
devices). 
9m.  A description of how other critical supplies and equipment will be transported is included.  5  9  10 
9n.  Determine a method to account for all individuals during and after the evacuation.  14  3  7 
9o.  Procedures are described to ensure that staff accompany evacuating residents.  12  1  11 
9p.  Procedures are described if a patient/resident becomes ill or dies in route.  1  2  21 
9q.  Mental health and grief counselors are available at reception points to talk with and counsel   
1  2  21 
evacuees. 
9r.  It is described whether staff family can shelter at the facility and evacuate.  5  5  14 
10.  Transportation & Other Vendors:  Establish transportation arrangements that are adequate for the type 
of individuals being served.  Obtain assurances from transportation vendors and other 
suppliers/contractors identified in the facility emergency plan that they have the ability to fulfill their 
commitments in case of disaster affecting an entire area (e.g., their staff, vehicles and other vital  17  1  6 
equipment are not overbooked, and vehicles/equipment are kept in good operating condition and with 
ample fuel.).  Ensure the right type of transportation has been obtained (e.g., ambulances, buses, 
helicopters, etc).  
11.  Train Transportation Vendors/Volunteers:  Ensure that the vendors or volunteers who will help 
transport residents and those who receive them at shelters and other facilities are trained on the needs of 
0  0  24 
the chronic, cognitively impaired and frail population and are knowledgeable on the methods to help 
minimize transfer trauma. 
12.  Facility Reentry Plan:  Describe who will authorize reentry to the facility after an evacuation, the 
procedures for inspecting the facility, and how it will be determined when it is safe to return to the facility 
8  2  14 
after an evacuation.  The plan should also describe the appropriate considerations for return travel back 
to the facility. 
13.  Residents & Family Members:  Determine how residents and their families/guardians will be informed of 
the evacuation, helped to pack, have their possessions protected and be kept informed during and 
1  18  5 
following the emergency, including information on where they will be/go, for how long and how they can 
contact each other. 
14.  Resident Identification:   
  14a.  Determine how residents will be identified in an evacuation; and ensure the following    
identifying information will be transferred with each resident* 
 
14a1.  Name.  13  4  7 
14a2.  Social Security Number.  4  4  16 
14a3.  Photograph.  6  3  15 
14a4.  Medicaid or other health insurer number.  5  4  15 
14a5.  Date of birth, diagnosis.  7  4  13 
14a6.  Current drug/prescription and diet regimens.  9  14  11 
14a7.  Name and contact information for next of kin/responsible person/Power of Attorney.  5  4  15 
*OIG analysis found that 17 of the 24 selected nursing homes emergency plans contained the first element of this task, Determine how residents will 
be identified in an evacuation. 
continued on next page 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  32 
   
   
Table C-1:  Centers for Medicare & Medicaid Services-Recommended Checklist Tasks Included in 24 
Selected Nursing Homes Emergency Plans (Continued) 
Nursing Home Plans 
Tasks (n=70)  With Tasks (n=24) 
M  PM  NM 
14.  Resident Identification  (Continued):     
  14b.  Determine how this information will be secured (e.g., laminated documents, water proof 
pouch around residents neck, water proof wrist tag etc) and how medical records and 
2  3  19 
medications will be transported so they can be matched with the resident to whom they 
belong. 
15.  Trained Facility Staff Members:  Ensure that each facility staff member on each shift is trained to be 
knowledgeable and follow all details of the plan. Training also needs to address psychological and 
emotional aspects on caregivers, families, residents, and the community at large.  Hold periodic reviews  0  17  7 
and appropriate drills and other demonstrations with sufficient frequency to ensure new members are 
fully trained. 
16.  Informed Residents & Patients:  Ensure residents, patients and family members are aware of    
and knowledgeable about the facility plan, including: 
16a .  Families know how and when they will be notified about evacuation plans, how they can be   
helpful in an emergency (example, should they come to the facility to assist?) and  2  1  21 
how/where they can plan to meet their loved ones. 
16b.  Out-of-town family members are given a number they can call for information.  Residents 
who are able to participate in their own evacuation are aware of their roles and  1  0  23 
responsibilities in the event of a disaster. 
17.  Needed Provisions:  [Processes for determining] if provisions need to be delivered to the facility 
residents  power, flashlights, food, water, ice, oxygen, medications  and if urgent action is needed to  1  5  18 
obtain the necessary resources and assistance. 
18.  Location of Evacuated Residents: [Processes for determining] the location of evacuated residents, 
document and report this information to the clearing house established by the state or partnering  2  4  18 
agency. 
19.  Helping Residents in the Relocation: [Training for staff]   Suggested principles of care for the 
relocated residents include: Encourage the resident to talk about expectations, anger, and/or 
disappointment; Work to develop a level of trust; Present an optimistic, favorable attitude about the 
0  2  22 
relocation; Anticipate that anxiety will occur; Do not argue with the resident; Do not give orders; Do not 
take residents behavior personally; Use praise liberally; Include the resident in assessing problems; 
Encourage staff to introduce themselves to residents; Encourage family participation. 
20.  Review Emergency Plan:  Complete an internal review of the emergency plan on an annual basis to 
ensure the plan reflects the most accurate and up-to-date information.  Updates may be warranted 
under the following conditions: regulatory change; new hazards are identified or existing hazards  11  0  13 
change; after tests, drills, or exercises when problems have been identified; after actual 
disasters/emergency responses; infrastructure changes; funding or budget-level changes. 
21.  Communication with the Long-Term Care Ombudsman Program:  Prior to any disaster, discuss the 
facilitys emergency plan with a representative of the ombudsman program serving the area where the 
facility is located and provide a copy of the plan to the ombudsman program. When responding to an  1  1  22 
emergency, notify the local ombudsman program of how, when and where residents will be sheltered so 
the program can assign representatives to visit them and provide assistance to them and their families. 
22.  Conduct Exercises & Drills:  Conduct exercises that are designed to test individual essential    
elements, interrelated elements, or the entire plan: 
 
22a.  Exercises or drills must be conducted at least semi-annually.  7  0  17 
 
22b.  Corrective actions should be taken on any deficiency identified.  8  0  16 
23.  Loss of Residents Personal Effects:  Establish a process for the emergency management agency 
representative (FEMA or other agency) to visit the facility to which residents have been evacuated, so  0  0  24 
residents can report loss of personal effects. 
Source:  Office of Inspector General analysis of 24 selected nursing homes emergency plans inclusion of CMS-recommended emergency 
preparedness planning tasks in 2010, using CMS, Survey & Certification:  Emergency Preparedness Checklist Recommended Tool for Effective 
Health Care Facility Planning.  Accessed at http://www.cms.gov  on February 5, 2010. 
 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  33 
  APPENDIX D 
Agency Comments:  Centers for Medicare & Medicaid Services 
(-l 
J"a. ..K:t:t .( 
DEPARTMENT OF HEALTH. HUMAN SERVICES  C0te!_Inc. e. 0.1.  Slo"r r"..4~ed~IcM. &_  Meo.:ald SeMen 
~A"''' 
""_lIVe 
200 It\depend"""l>  SW 
WashlnglM. DC 2020' 
JAN 0 5 201l 
DATE: 
TO: 	 Daniel R. Levinson 

Inspector Oeneral 

FROM:  -M~TlNenner 

ActinA Adm~istralor 

SUBJECT: 	 Office of Inspector Gcnerd.l (010) Draft Report: "Oaps Continue To Exist In 
Nursing Horne Emergency Preparedness and Response During Disasters: 2007
2010 (OEI-06-0900270)" 
Thank you for the: opportunity to review and comment on the subject 010 dralt report. OIG's 
study focused on determining compliance with Federal regulations and compan.'d emergency 
plans tOT selected nursing homes against the Centers for Medicare &. Medicaid Services (eMS) 
checklist for health care facilities. Inforrnaiion was also collected about the roles ofStale long
term care (LTC) ombudsman programs and State Agencies (SAs) in assisting musing homes 
during these disasters.  During this study, OIU's findings were: 
 	 In 2009-2010, 92 percent of nursing homes met Federal regulations for emergency pllL'ls 
and n percent for emergency tmining, slightly less than 5 years earlier. 
 	 On average, selecll.'t:j nursing bomes' emergency plans included about half of the CMS
recommended checklist tasks, and none included all. 
 	 Administrators from 17 of the 24 selected n.ursing homes reported subsiantial challenges 
in responding to disasters. 
 	 LTC ombudsmen ""'ere often unable to foous on nursing horne residents during, disasters. 
 	 State Agencies completed tasks related to nursing home compliance and addressed ad hoc 
facility needs. 
In its report. 0[0 made four recommendations to the Secretary of Heatth and HUman Services 
Md the Administrator of CMS. In making these recommendations. OIG took into consideration 
there are no requirements for use ofeMS Emergency Preparedness chf.!Cklists as well as the 
continued need to respond to disasters to protect resident health. safety. welfare. and rights 
during Md after disasters. Our response to these ....'Cornmendations is slated below. 
OIG Recommendation 
e MS revise Federal regulations by identifying and including in its regulations requirements for 
specific elcment~ of emergency plans and training. 
OEI-06-09-00270  Gaps Continue To Exist in Nursing Home Preparedness  34   
   
Centers for Medicare & Medicaid Services (continued)
 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  35 
   
   
Centers for Medicare & Medicaid Services (continued)
 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  36 
   
   
Agency Comments:  Administration on Aging  
 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  37 
   
   
Administration on Aging (continued) 
 
 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  38 
  Administration on Aging (continued) 
Pa~~3 
AoA Response 
Om-06-09-00270 
In its support orStlites' emergency prcpllfcdl1C$' activities, AoA provides. runo.ng other things: 
 	 An enlC1llcocy preplltedness webpage on the AoA websile: 

lm :llwww  .  v, AoARoot/Pg;parednessli  . and 

 	 Emergeocy preparedness planning resources for state plan 00 aging development as part 
of the AnA-supported TA  se Planning Zone ofthe Jl.atiunal Association of States United 
for Aging and Disabilities (NASUAlJ)~ 
httnJtwy.. ",lli!$Uild,9n:/tllSc/cmmC!wy llIJoomIom ('S5IlU1CC',htm I. 
The Administration on Aging would Itgain like ro thank the OlG -jor their work in conducting thb 
review. If we Clltl be of further wisumce. please let me know. 
yG~ 
OEI-06-09-00270  Gaps Continue To Exist in Nursing Home Preparedness  39   
   
ACKNOWLEDGMENTS 
This report was prepared under the direction of Kevin K. Golladay, 
Regional Inspector General for Evaluation and Inspections in the Dallas 
regional office;  A. Blaine Collins, Deputy Regional Inspector General; 
and Ruth Ann Dorrill, Deputy Regional Inspector General.   
Deborah Cosimo served as the project leader, and Petra Johansson was the 
lead analyst.  Other principal Office of Evaluation and Inspections staff 
from the Dallas regional office who contributed to the report include Leah 
Bostick, Nathan Dong, Ben Gaddis, Anthony Guerrero-Soto, and Chet 
Yean; central office staff who contributed include Jennifer Jones, Kevin 
Farber, and Sandy Khoury. 
 
 
OEI-06-09-00270   Gaps Continue To Exist in Nursing Home Preparedness  40 
   
Office of Inspector General 
http://oig.hhs.gov 
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as amended, is 
to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as the 
health and welfare of beneficiaries served by those programs.  This statutory mission is carried out through 
a nationwide network of audits, investigations, and inspections conducted by the following operating 
components: 
Office of Audit Services 
The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting audits with 
its own audit resources or by overseeing audit work done by others.  Audits examine the performance of 
HHS programs and/or its grantees and contractors in carrying out their respective responsibilities and are 
intended to provide independent assessments of HHS programs and operations.  These assessments help 
reduce waste, abuse, and mismanagement and promote economy and efficiency throughout HHS. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide HHS, Congress, 
and the public with timely, useful, and reliable information on significant issues.  These evaluations focus 
on preventing fraud, waste, or abuse and promoting economy, efficiency, and effectiveness of 
departmental programs.  To promote impact, OEI reports also present practical recommendations for 
improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations of fraud and 
misconduct related to HHS programs, operations, and beneficiaries.  With investigators working in all 
50 States and the District of Columbia, OI utilizes its resources by actively coordinating with the 
Department of Justice and other Federal, State, and local law enforcement authorities.  The investigative 
efforts of OI often lead to criminal convictions, administrative sanctions, and/or civil monetary penalties. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, rendering 
advice and opinions on HHS programs and operations and providing all legal support for OIGs internal 
operations.  OCIG represents OIG in all civil and administrative fraud and abuse cases involving HHS 
programs, including False Claims Act, program exclusion, and civil monetary penalty cases.  In 
connection with these cases, OCIG also negotiates and monitors corporate integrity agreements.  OCIG 
renders advisory opinions, issues compliance program guidance, publishes fraud alerts, and provides other 
guidance to the health care industry concerning the anti-kickback statute and other OIG enforcement 
authorities.