Bioterrorism and Other Public Health Emergencies 

Tools and Models for Planning and Preparedness 

Nursing Homes in Public Health Emergencies 

Special Needs and Potential Roles 

Focus Group Discussions of Disaster Planning at Nursing Homes 

Prepared for: 

Agency for Healthcare Research and Quality 

U.S. Department of Health and Human Services 

540 Gaither Road 

Rockville, MD 20850 

www.ahrq.gov

Contract No. 290-00-0018

Prepared by: 

RTI International 

Lead Investigators: 

Elisabeth D. Root, M.A. 

Jacqueline B. Amoozegar 

Shulamit Bernard, Ph.D. 

AHRQ Publication No. 07-0029-1 

May 2007 
Funding to support Nursing Homes in Public Health Emergencies: Special Needs and Potential 

Roles was provided by an Agency for Healthcare Research and Quality contract to RTI 

International (contract no. 290-00-0018). 

The authors of this report are responsible for its content. No statement in the report should be 

construed as an official position of the Agency for Healthcare Research and Quality or the U.S. 

Department of Health and Human Services. 

This document is in the public domain and may be used and reprinted without permission except 

those copyrighted materials noted, for which further reproduction is prohibited without specific 

permission of copyright holders. 

Suggested Citation: 

Root ED, Amoozegar JB, Bernard S. Nursing Homes in Public Health Emergencies: Special 

Needs and Potential Roles. Prepared by RTI International under Contract No. 290-00-0018. 

AHRQ Publication No. 07-0029-1. Rockville, MD: Agency for Healthcare Research and 

Quality. May 2007. 

ii 
Contents 

Executive Summary ...................................................................................................................1 

1. Introduction.......................................................................................................................5 

1.1 Background on Nursing Home Disaster Preparedness ............................................5 

1.2 Organization of this Report......................................................................................6 

2. Data and Methods .............................................................................................................9 

2.1 Sample Selection......................................................................................................9 

2.2 Participant Recruiting and Characteristics.............................................................10 

2.3 Protocol Development ...........................................................................................11 

2.4 Data Collection and Analysis.................................................................................11 

2.5 Study Limitations...................................................................................................11 

3. Focus Group Results.......................................................................................................13

3.1 Disaster Preparedness and Planning Activities......................................................13 

3.2 Special Needs of Nursing Homes ..........................................................................16 

3.3 Potential Roles of Nursing Homes.........................................................................20 

3.4 Influence of State Regulations on Nursing Homes................................................25 

3.5 The Role of the Red Cross and the Effects of Hurricane Katrina..........................26 

 4. Conclusions.........................................................................................29 

References................................................................................................................................31 

Appendixes 

A: Focus Group Moderators Guide.................................................................................33 

 B. Long-Term Care Preparedness Needs Assessment........................................35

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iv 
Executive Summary 

The events of September 11th and the devastation caused by hurricane Katrina demonstrate 

the impact of such events on the public health infrastructure and the importance of emergency 

preparedness activities. In addition, the reality of bioterrorism, as exemplified by the anthrax 

cases reported in the U.S., underscores the importance of preparing for possible bioterrorist 

attacks. To date, most health care preparedness planning efforts are focused on hospital and first 

responder preparedness. Nevertheless, we know that the elderly population is particularly 

vulnerable to bioterrorism and other public health emergencies due to their complex physical, 

medical and psychological needs. The potential role and question of preparedness on the part of 

nursing homes has emerged in local and national preparedness discussions. However, we have 

little understanding of the extent to which nursing homes have planned for and/or been 

incorporated into regional planning efforts (Saliba et al., 2004; Dosa et al., 2003; Helget et al., 

2002). 

To address this issue, a series of focus groups were conducted to collect information about 

disaster and bioterrorism related planning activities among nursing homes in five States -- North 

Carolina, Oregon, Pennsylvania, Washington, and Utah -- and Southern California. The aims of 

the focus groups include: 

• Determine if nursing home administrators have prepared and trained staff on disaster 

plans, including bioterrorism response 

• Assess the special needs of the elderly population in nursing home settings during a 

public health emergency 

• Determine if nursing homes are able to accommodate patient flows from acute care 

hospitals or provide other resources 

• Assess the impact of State regulations on the ability of nursing homes to offer support 

and/or surge capacity 

Focus Group Methods

 The focus group discussions included topics such as the level of preparedness activities, 

special needs of nursing home environments/populations, ability to accept transfers, provide 

basic medical care and other support, and the influence of State regulations on disaster planning. 

Using a convenience sampling strategy, RTI used its Integrated Delivery System Research 

Network (IDSRN) partners to assemble the focus groups. The IDSRN is a model of field-based 

research designed by AHRQ to link the Nation’s top researchers with some of the largest health 

care systems to conduct research on cutting-edge issues in health care on an accelerated 

timetable. 

IDSRN partners were asked to recruit staff from three to six nursing home facilities in their 

respective State(s) to participate in the focus group. Each focus group consisted of between 4 

and 10 participants for a total of 49 participants. In selecting participants, IDS partners were 

asked to identify facilities characterized by: (1) high patient flows to one of their hospital 

facilities or (2) a rural location or strategic location in vulnerable communities where hospital 

1 
capacity or even response planning is low. Standard focus group techniques were used (Morgan 

and Kreuger, 1998) to collect and analyze data. Results across all focus groups were compared 

to identify major themes present in all six States as well as situations unique to one or two States 

or facilities. 

Disaster Preparedness and Planning Activities 

 While all nursing homes we spoke with engage in some form of disaster planning, the 

focus, frequency and coordination of these activities varied by facility: 

• Nursing homes have plans in place for some public health emergencies, but had not done 

planning specific to bioterrorism. Disaster plans appear to focus on natural disasters most 

prevalent in a region (e.g. wild fires, earthquakes, floods, hurricanes).

• All nursing homes conduct quarterly fire drills, staff in-service trainings, and annual or 

semi-annual disaster drills. The topics addressed in trainings are highly dependent on 

facility location and State requirements.

• The level of local coordination around disaster planning differs by State. Nursing home 

representatives, for the most part, reported little involvement in regional coordination 

efforts.

Special Needs of Nursing Homes 

Focus group participants voiced a variety of needs, some of which were unique to nursing 

homes and some which would be problematic to a variety of health facilities: 

• Nursing homes are concerned about caring for special patient populations during an 

emergency (e.g. Alzheimer’s, cognitively impaired, or high fall patients). 

• Concerns about staffing in an emergency were universal, since many staff members will 

want to care for their own families during an emergency. 

• Nursing home representatives are concerned about running out of pharmaceutical and 

other medical supplies in a disaster. 

• The adequacy of fuel supplies to power generators is a major concern because power 

serves a number of important functions in these facilities. 

• Nursing homes are concerned about having sufficient food and water supplies. 

Potential Roles of Nursing Homes 

Focus group participants suggested a number of activities nursing homes could engage in 

during a public health emergency: 

• Nursing homes represented are willing to accept residents from area hospitals but voiced 

concerns about patient acuity and facility capacity and staffing. 

• Nursing homes could provide basic medical care and short term shelter for community 

residents. 

• Nursing home facilities have little excess space and should not be used to store 

equipment or stockpile drugs. 

2 
Influence of State Regulations on Nursing Homes 

 State regulations did not appear to be a strong factor influencing how nursing homes would 

respond during a public health emergency: 

• Participants were largely unaware of State regulations governing nursing homes during a 

disaster or public health emergency. 

• Nursing homes need formal guidance as well as resources to develop disaster plans. 

Two additional themes emerged in several of the focus groups, one related to the role of the 

Red Cross and the other was motivated by Hurricane Katrina: 

• Nursing homes are uncertain about the role of the Red Cross during a public health 

emergency. 

• Hurricane Katrina provoked fears of liability and judgment, decreased confidence that the 

government will be a source of support in an emergency, and resulted in changes to the 

duration of time for which nursing homes think they need to be self-sustaining in an 

emergency.

3 
4 
Section 1. Introduction

1.1 Background on Nursing Home Disaster Preparedness 

The events of September 11th and the devastation caused by hurricane Katrina demonstrate 

the long-term impact of such events to the public health infrastructure and the importance of 

emergency preparedness. In addition, the reality of bioterrorism, as exemplified by the anthrax 

cases reported in the U.S., underscores the importance of preparing for possible bioterrorist 

attacks. Despite the fact that significant progress has been made in overall preparedness, our 

ability to detect bioterrorist threats, communicate these in real time to the clinical, public health, 

and lay communities, and effectively triage and treat afflicted populations continues to raise 

concern. This is especially true for certain vulnerable populations, such as the elderly, whose 

unique psychological and medical needs require special attention. 

As the U.S. population continues to age, nursing homes have become an increasingly 

important component of the U.S. health system. The 2004 National Nursing Home Survey 

estimates that nearly 1.5 million adults are admitted to the Nation’s 16,100 nursing homes each 

year (CDC, 2004). Nearly half of all women and a third of all men are expected to use nursing 

home care at some point during their lives (Spillman and Lubitz, 2002). Despite their role in 

serving an increasing proportion of the Nation’s population, nursing facilities have been 

overlooked as health resources and are often not incorporated into larger disaster planning 

efforts. This may be, in part, because of the difficulties involved in integration and coordination 

of stakeholders across the health care continuum. However, this interorganizational 

collaboration is imperative for effective and coordinated disaster response (IOM, 2002). A 

complex network of local, State, and Federal government agencies must work together 

efficiently with community-based providers of care. Federal agencies have endeavored to 

provide the health care community with relevant information on threats of bioterrorism and other 

public health emergencies and work with communities in relief efforts following natural and 

man-made disasters. Nevertheless, only a handful of limited efforts focus on the mechanics of 

producing viable regional plans and availing surge capacity in times of need. 

Most health care preparedness planning efforts are focused on hospital and first responder

preparedness. Nevertheless, the elderly are particularly vulnerable to bioterrorism and other 

public health emergencies because of their complex physical, social and psychological needs. 

The potential role and needs of preparedness on the part of nursing homes has emerged in local 

and national preparedness discussions, especially in the wake of Hurricane Katrina. A recent 

workgroup sponsored by the Health Resources and Services Administration (HRSA) 

recommended the development of an interdisciplinary evidence-based curriculum on emergency 

preparedness that would allow health professionals working with the elderly population to better 

address the medical needs of their population in an emergency. However, we have virtually no 

understanding of the extent to which nursing homes have planned and/or been incorporated into 

regional planning efforts (Saliba et al., 2004; Dosa et al., 2003; Helget et al., 2002). A pilot 

study in the Greater Pittsburgh, Pennsylvania area found that nursing home facilities and their 

medical staffs were largely unprepared to recognize and respond to a bioterrorist event. Lack of 

personal knowledge and financial resources were cited as two of the most common barriers to 

preparedness and planning (Dosa et al., 2003). The purpose of this report is to address this gap 

5 
in knowledge of the role nursing homes could play with respect to regional preparedness. We 

hypothesize that nursing homes may strategically contribute to preparedness in their 

communities, especially in those communities where no hospital facility is located. Ancillary to 

this report, a model needs assessment tool for determining the readiness of longterm care 

facilities for public health emergencies is included in Appendix B. 

In 2004, The Agency for Healthcare Research and Quality (AHRQ) expanded its 

Bioterrorism Planning and Response research portfolio to include several projects that focus on 

surge capacity issues. In doing this, AHRQ recognized the need to better understand two priority 

areas: (1) identify ways to augment hospital bed capacity, and (2) use models to set surge 

requirements. In this report, we present the findings of a series of focus groups conducted with 

nursing home staff in five States -- North Carolina, Oregon, Pennsylvania, Washington, and Utah 

-- and Southern California. The purpose of the focus groups was to gauge the level of disaster 

preparedness and assess the special needs and potential role of nursing homes in the event of 

bioterrorism or other public health emergencies. The focus groups were used to address the 

following research questions: 

1. Have nursing home administrators prepared and trained staff on disaster plans? 

2. Do nursing homes have special needs associated with the elderly population that should 

be addressed? 

3. Are nursing homes able to accommodate patient flows resulting from acute care hospital 

needs to free beds for surge capacity? 

4. How do State regulations influence the ability of nursing homes to offer support and/or 

surge capacity? 

5. In addition to beds, what other surge capacity capabilities might nursing homes offer? 

Findings from this report can provide important insight into current nursing home 

preparedness activities as well as the potential role of nursing homes in larger local or regional 

preparedness efforts and the special needs experienced by the nursing home population. 

1.2 Organization of this Report 

This report is the second report prepared for this project. The first report, The Emergency 

Preparedness Atlas: U.S. Nursing Home and Hospital Facilities combines findings from 

interviews with State disaster coordinators with information obtained through a larger 

environmental assessment to consider issues of regional planning concordance relevant to 

preparedness and response of hospitals and nursing homes in disaster situations. In conducting 

this environmental assessment, we used geographic information systems (GIS) to synthesize and 

analyze the distribution of nursing home and hospital facilities across the United States and 

present the results as a series of State- and regional-level maps. 

In the remainder of this report, detailed methods and findings of the nursing home focus 

groups are presented. Section 2 presents an overview of the methods used to compile data for 

this report. Section 3 presents a synthesis of the focus group results organized into several broad 

topic areas. Limitations of the study and conclusions about nursing home preparedness and their 

role in public health emergencies are presented in Section 4. 

6 
An ancillary model survey, also prepared for this project, is included at the end of this report 

in Appendix B. The Longterm Care Preparedness Needs Assessment tool can help regional and 

State planners and individual longterm care facilities determine their readiness for public health 

emergencies. 

7 
8 
Section 2. Data and Methods 

2.1 Sample selection 

Five States -- Washington, Oregon, North Carolina, Utah, and Pennsylvania -- and Southern 

California were selected for focus groups using a convenience sampling strategy. A convenience 

sample is technically “...any strategy other than simple or stratified random sampling” 

(Maxwell, 1996: 70). While not preferred, the most feasible approach in some situations is to 

use a convenience sample. Our main goal for using this approach was to engage all of RTI’s 

IDSRN partners who expressed an interested in studying the project research questions. 

Using a convenience sampling strategy, RTI used its Integrated Delivery System Research 

Network (IDSRN) partners to assemble the focus groups. The IDSRN is a model of field-based 

research designed by AHRQ to link the Nation’s top researchers with some of the largest health 

care systems to conduct research on cutting-edge issues in health care on an accelerated 

timetable. 

Four IDS partners were involved in this effort: Intermountain Health Care (Utah), 

Providence Health System (California, Oregon and Washington), UNC Health Care (North 

Carolina) and UPMC Health System (Pennsylvania). Since IDS partners were asked to identify 

and recruit staff from affiliated nursing homes, working with motivated IDS partners (rather than 

attempting to recruit participants using cold calls) resulted in good participation rates for focus 

groups. RTI’s IDSRN consists of a diverse group of hospitals and health systems that adequately 

capture the heterogeneity of nursing homes across the U.S. Our six-State sample reflects 

diversity in five dimensions: 

− Geographic 

− Level of progress and degree of coordination in both health care delivery and 

bioterrorism preparedness planning 

− State laws and regulations related to nursing homes services and licensure 

− Supply and demand conditions for nursing home and hospital beds 

− Organizational policies and practices 

In selecting participants, we asked IDS partners to identify facilities characterized by: (1) 

high patient flows to one of their hospital facilities, or (2) a rural location or strategic location in 

vulnerable communities where hospital capacity or event response planning is low. The purpose 

for this selection strategy was to identify nursing homes that would be most affected by 

necessary discharge from the hospital back to the nursing home as well as those nursing homes 

that are pivotally located and could offer staff/storage/dispensing capabilities to an IDS facility 

in the event of a public health emergency. 

9 
2.2 Participant Recruiting and Characteristics 

For each State, we recruited staff from three to six nursing home facilities to participate in 

the focus group. Several facilities elected to send two representatives. Each focus group 

consisted of between 4 and 10 participants. Recruiting was done by IDS partner staff via email 

inquiries. Once facilities committed to attend the focus group, RTI staff sent a confirmation 

letter to each attendee explaining the purpose of the focus group and providing logistical 

information. Participants represented a wide range of roles and expertise ranging from executive 

directors, administrators, and directors of nursing to quality managers, disaster coordinators, and 

case managers. Table 1 lists characteristics of the focus group participants. Each participant was 

paid $250 as an incentive to travel and participate in the focus group. When possible, we asked 

facilities to bring a copy of their disaster plan. 

Table 1: Characteristics of Focus Group Participants 

State No. Nursing Homes 

Represented 

No. 

Participants Participant Titles 

California 6 10 1 Executive Director 

1 President 

4 Administrators 

1 Director of Case Management 

1 Director of Quality Resources 

1 Director of Plant Operations 

1 Director of Clinical Services 

North Carolina 4 8 3 Administrators 

2 Directors of Nursing/Clinical Services 

2 Disaster Coordinators 

1 Director of Community Contacts/Special Projects 

Oregon 9 9 1 Executive Director 

3 Administrators 

1 Corporate Compliance Officer 

2 Staff Development Coordinators 

1 Vice President of Risk Management 

1 Environmental Services Director 

Pennsylvania 4 6 2 Medical Directors 

2 Administrators 

1 Executive Director 

1 Director of Resident Services 

Utah 3 4 3 Administrators 

1 Director of Nursing 

Washington 3 4 2 Administrators 

1 Director of Nursing 

1 Quality Manager 

Total 29 41 

10 
2.3 Protocol development 

The primary purpose of the focus groups was to provide a multi-institutional view of the 

special needs and potential roles of nursing homes in surge capacity. This allows us to 

understand the nursing home perspective across diverse conditions and threat scenarios faced in 

the six States included in our sample. We developed a focus group protocol drawing directly 

from our stated research questions. The protocol focused the discussions on topics such as the 

level of preparedness activities; special needs of nursing home environments/populations; ability 

to accept transfers, provide basic medical care and other support; and the influence of State 

regulations on disaster planning. 

 

The focus group protocol was pilot tested in North Carolina and minor revisions were made 

for subsequent focus groups. After the first focus group, several questions were dropped that did 

not affect comparability of results across the six focus groups. The focus group moderator’s 

guide can be found in Appendix A of this report. 

2.4 Data collection and analysis 

Each focus group took approximately one and one half hours. Standard focus group 

techniques (Morgan and Kreuger, 1998) were used to collect and analyze data. Each focus group 

was run by a two-person focus group team: one facilitator and one note-taker. Senior RTI staff 

trained in focus group moderation techniques ran each focus group and a junior staff member 

took notes using a laptop computer. All focus groups were audio-taped. Results from the focus 

groups were transcribed and analyzed. Results were compared across all focus groups to identify 

major themes present in all six States as well as situations unique to one or two States or 

facilities. Personal or facility names are not used in this report in order to preserve the 

confidentiality of participants. 

2.5 Study Limitations 

Focus groups have a number of methodological limitations. First, focus groups gather the 

perspective of a limited number of participants and are therefore not generalizable to the larger 

population. While focus groups have high face validity because they rely on comments obtained 

directly from participants, it is important to keep in mind that results are only representative of 

the population involved in the focus groups. Second, focus groups require special moderating 

skills. The use of open ended questions and probes and the understanding of when to focus on a 

question and when to move on to a new topic area require a certain degree of expertise. Senior 

staff members responsible for moderating the focus groups have significant experience and 

training in focus group methodology.

11 
12 
Section 3. Focus Group Results

In this chapter the results of the six focus groups are organized into five topic areas: disaster 

preparedness and planning activities, special needs identified by nursing home staff, potential 

roles facilities could play during a disaster or other public health emergency, the influence of 

State regulations on preparedness and planning, and the role of the Red Cross and effects of 

Hurricane Katrina. 

3.1 Disaster Preparedness and Planning Activities 

Nursing homes have plans in place for some public health emergencies but have not 

done planning specific to bioterrorism. For the most part, participants reported their facilities 

had done planning for disasters or emergencies such as fires, major snow storms, earthquakes 

and hurricanes. However, only a couple participants reported planning activities specific to 

bioterrorism. Many participants acknowledged the importance of planning for bioterrorism or 

infectious disease outbreaks such as flu (and tended to categorize these two events together), but 

most admitted that it was “not on the radar screen”, far down on the “list of priorities” or had 

“fallen off the table” in the years following 9/11. Several facilities reported developing new 

policies and procedures specific to anthrax. For the most part, participants noted that their State 

regulatory and licensing agencies require they train staff for fires and other “disasters,” but 

bioterrorism planning has never been required: 

The State requires that we have disaster training and fire drills. We do drills for 

earthquake or power disruption...But terrorism, disasters, things like that have not been 

part of the required drills...have not been part of my planning. 

We are required to have 2 disaster drills a year. We do take into account fires, power 

outages, earthquakes, tornadoes...We’ve not really done much with bioterrorism. 

We don’t really have anything set up that’s formal for bioterrorism. We do have disaster 

preparedness but not specifically targeted to bioterrorism...fire, weather related, if we 

get to the point where we need to move residents out. 

One participant noted that a comprehensive disaster plan, including bioterrorism 

preparedness, is “required as part of JCAHO accreditation.” 

For the few facilities that reported some level of bioterrorism or infectious disease planning, 

the level of planning varied greatly. One facility reported developing a plan in the immediate 

wake of 9/11 but the participant noted “I can’t tell you a single thing that’s in it or where it’s 

located”. Another participant reported using in-service trainings to review “signs and symptoms 

or what to be aware of” as well as what measures to take to protect residents, staff, and the 

facility if an infectious agent is identified. These trainings tended to be short (5 to 10 minutes in 

duration) and focused on flu, norovirus, and other common illnesses. Another participant who 

had been affiliated with the military before taking her position with the nursing home reported: 

13 
We’ve looked at our infection control and how we would handle a biological agent, how 

we would detect that. We have periodic training with the staff and try to go through each 

of the different areas. We have a rather...thick disaster manual. So at staff meetings we 

try to go through each of the sections and keep it in the forefront of their minds. 

This was undoubtedly the most developed bioterrorism response among all nursing homes 

with which we spoke. Another facility had recently been involved in a HAZMAT scare when a 

contaminated patient was admitted to the attached hospital. This participant also reported a 

higher level of bioterrorism planning: 

We have been involved with the bioterrorism process on the hospital side with the grant 

writing in terms of getting decontamination showers and some of the equipment...We 

recently spent time brushing up on bioterrorism and chemical effects. 

All nursing homes conduct drills and staff trainings, but topics addressed in training 

are highly dependent on facility location. All focus group participants reported conducting fire 

and disaster drills, as required by State licensing and regulatory agencies. Quarterly fire drills 

and semi-annual disaster drills appeared to be the norm among most facilities, although some 

facilities held more frequent disaster drills: 

We do 12 hour shifts so we have 2 shifts; both do quarterly fire drills and semi-annual 

disaster drills...In addition, we do an in-service, once a year. We have a big fire and 

disaster in-service for all staff. Because when you look at just doing drills four times a 

year and disasters twice a year to two shifts, we may miss some of our employees.

[We] do fire drills, and once a quarter we have a disaster drill...whether it’s an external 

disaster where we’re taking in patients or an internal disaster where we have to ship 

patients out...it’s done on all three shifts each quarter. It’s a State requirement. 

The types of disaster events that facilities focused on depended on the types of natural 

disasters prevalent in their location. Facilities in Southern California, Oregon, and Washington 

tended to focus on earthquake preparedness: “At least once a year we do a disaster drill...that is 

all internally focused. Usually we pretend it’s something like an earthquake.” One facility 

described an elaborate drill involving volunteers that act like patients and wear make up and tags 

that describe their medical condition: 

At least once a year...we have the facility suffer an earthquake. We scatter people 

around with various identification items on them, and we have a command center that 

we’ve established though this training process...staff have to find people, triage them. 

We have a disaster at such time of the day that the shift changes. 

Facilities in Southern California also reported preparing for wild fires while facilities in 

Washington and Oregon were more concerned with major snow storms and flooding. 

Participants in North Carolina were concerned with hurricanes and flooding while participants in 

Utah mentioned tornadoes and power outages. All facilities reported tailoring their disaster plans 

to these events. 

14 
Nearly all participants agreed that high staff turnover rates were a significant barrier to 

ensuring that staff are adequately trained for a disaster. In general, participants stressed that they 

go over disaster activities during orientation but expressed concern about whether this level of 

training is adequate. According to one participant, “we try to emphasize where to find 

information on what to do rather than what they should do”. Other participants reported 

spending a significant amount of time addressing the details of the disaster plan with new staff: 

I do an orientation myself with all the new employees that specifically deals with disaster 

and fire drill rules. We go over where the electrical shop is and if it’s an earthquake we 

go over where the main gas line turn-off is (in case there’s a rupture in the line) and the 

main line water cut-off. I cover that specifically with each new employee. 

I think you just have to ensure that in your general orientation there is a safety portion 

and that people go and see where the gas the water and electricity shut-off areas are so 

they get the basics...You have to make sure that people know what to do. 

Differing levels of local coordination around disaster planning are evident in different 

States. A consistent theme across focus groups was the lack of involvement in local or State 

emergency planning activities by nursing home facilities. While several participants reported 

being involved in emergency or disaster planning meetings that took place immediately after 

9/11, these meetings ended up being more information for nursing home administrators. 

According to one participant: 

After 9/11...[our county] had a focus group looking at these issues...they were very 

focused on trying to organize within the county and included LTC in the focus but...you 

feel like you’re a fly on the wall...there are hundreds of people there from major 

agencies, fire and police...I went to a couple meetings but it was more informational for 

me than giving input or trying to say ‘we offer these services.’ 

One State had recently organized an emergency and disaster planning forum specifically for 

long-term care facilities that included a “task force of nursing homes.” Focus group participants 

reported that representatives from that State asked for input on changes to rules and regulations 

that might be necessary in the event of an emergency. Participants in other States reported trying 

to coordinate with local or State emergency planning agencies with little success. One 

participant noted that she “attempted to get our county disaster preparedness representative 

involved with our facility” but was never able to. Another participant reported, “We haven’t had 

much support from our local government. When you try to contact them to get somebody out to 

come to the building to help, there’s really nothing or nobody available.” Other focus group 

participants reported speaking with city or local community emergency planning agencies but 

did not find the interactions helpful:

We’ve been working with the city, local community services, and talked with them. They 

had some suggestions...we talked abut [our disaster plan] and reviewed it. They really 

wanted to focus on the fact that for the first 72 hours we’re on our own. But we want to 

think longer term than that. 

15 
One participant pointed out that the local health departments in more rural areas of the State 

are “less effective” than those located in urban areas, making coordination even more difficult in 

these areas. Several participants suggested that this lack of coordination at the local level 

jeopardizes the utility of the disaster plans that nursing homes have put in place because they will 

unknowingly be relying on the same resources as other organizations in their communities. 

According to one participant, “I bet our disaster plan and the one of the organization next door 

are both relying on the same five ambulances.” 

Participants in one State were particularly adamant that nursing homes should not be 

included as a resource in local or regional disaster plans. According to one participant, “a 

nursing home historically is not part of any disaster plan...when you think of a disaster plan, the 

community number one resource: hospital. Nursing home is really not part of that equation.” 

Facilities expressed a number of reasons why nursing homes are not suited to be a good resource. 

One participant pointed out that only nurses are available for patient care because “the doctor 

doesn’t stay on site at the nursing home.” Another participant stated that while nursing homes 

often have the largest facility in many communities, “most nursing homes would not have that 

space available” because they are “not designed to accept additional patients.” Other facilities, 

such as schools, have large auditoriums and lunch rooms that could be used to help community 

members. Two participants started negotiations with local community services but eventually 

backed out because “the administrative decision of the facility was that we have other things on 

the fire that are priorities.”

3.2 Special Needs of Nursing Homes 

Nursing homes have concerns about caring for special patient populations during an 

emergency. Most focus group participants reported that one of their principal concerns in a 

disaster situation would be caring for the special populations in their facility with limited 

cognitive and/or physical abilities. Caring for residents with Alzheimer’s disease or dementia 

during an emergency situation was of particular concern for many facilities. Participants stressed 

the importance of maintaining a calm, routine-based environment to avoid “losing this group to 

bad behaviors.” One participant explained that these patients are especially vulnerable to the 

stress of a disaster. If pharmaceutical supplies ran out or were destroyed and these patients were 

without their medications, “it could be a very dangerous situation” because “without their meds 

[these patients] are extremely dangerous to themselves and others.” 

Residents with Alzheimer’s and dementia are typically located in locked units where staff 

can monitor them very closely. Some facilities indicated that they have monitoring systems (e.g., 

WanderGuard®) in place to prevent residents with these conditions from wandering beyond 

supervised areas. In the case of a power outage, these systems would cease to function (as they 

require electricity), resulting in the need for additional staff to supervise and redirect these 

residents to keep them safe. Two participants remarked on redirection of wanderers: 

[Our last stage Alzheimer’s folks] would absolutely not know which way to go. You 

would have to have staff down there doing constant redirection...You would need to have 

concentrated staff down there. 

16 
We would try to assign somebody to stay by the main entrance door. So, if they did make 

their way down the elevator if it’s working...Of course, in a power outage, it wouldn’t 

be... But, if they did manage to go down the stairs, there would be somebody there 

stationed. That is the primary space that they would be able to get out. Even if the system 

went down, they would be caught. 

When asked, not all of the facilities with these monitoring systems knew if their systems 

were hooked up to the generator. Even in cases where these systems are hooked up to the 

generator, concerns about the longevity of fuel supplies would be salient. 

Focus group participants also addressed the increased time and attention that would need to 

be devoted to patients lacking the cognitive skills to understand and/or communicate about an 

emergency situation. Some facilities reported having formal procedures in place for handling 

such patients in an emergency. One participant explained that “just going around and letting 

them see you and touching them and saying ‘It’s okay, we’ve got it under control’ is a very 

positive thing.” However, this would require additional staff that may or may not be available. 

While a few focus group participants briefly touched on the special needs of high-fall 

patients, concerns about caring for patients with limited physical abilities typically arose in the 

context of logistical difficulties involved in evacuating them. One participant shared her fear 

that the equipment (e.g., wheelchairs) needed to transport bed-bound and vegetative patients 

would be destroyed in the disaster. Another participant explained that his staff has been trained 

in performing “blanket and emergency carries” to handle circumstances such as these. 

Concerns about staffing in an emergency were universal. Adequacy of staffing impacts 

the ability of nursing homes both to successfully maintain normal operations for their current 

residents and to take on additional roles during an emergency. A number of focus group 

participants emphasized the importance of maintaining normal operations and standards of care 

to the best of their ability in an emergency. They acknowledged that this would be extremely 

difficult to achieve without additional assistance, much less with the reduced staff that they 

would likely have given the circumstances: 

Our facility would be in dire need of assistance if not enough staff came in. In the event 

of a crisis, we would need more staff than normal. 

Many facilities had clearly given substantial thought to how they would induce the staff 

needed to maintain normal operations to stay at or come to work. A few nursing homes said 

they had facilities available to care for staff member’s families and children and would 

encourage staff to bring their families. Other facilities were prepared to provide nursing staff 

with rooms and food. One participants remarked “...if [staff] are unable to get home or there is a 

possibility that they won’t be able to get back we do have them stay in the facility, give them a 

bed, they can stay right there.” Some nursing homes mentioned having the capacity to care for 

children of staff that report to work. According to one participant: 

One of the things I tell staff is, ‘In the absence of communication, come on in. Bring your 

families...we will provide.’...Their homes may be destroyed. Maybe they didn’t plan. 

17 
Maybe they don’t have water on-site...They know that they have a link. In us taking care 

of them, hopefully we will be able to continue providing care. 

A number of nursing homes also had put plans in place to provide transportation to the 

facility for staff and their families. Several nursing homes reported having facility vehicles 

available to pick up staff members and transport them to the facility for work while one (urban) 

facility reported supplying staff with taxi vouchers: 

In an emergency we’d go pick up people...use our service vehicles to do that...And we 

have had staff come in with their children and have something set up for their kids 

We have a system in place where one of our maintenance people...will go pick up people. 

Either that or if he’s unable to do it...we have taxi vouchers available. 

Other potential solutions for staffing problems included: arranging to trade staff with other 

facilities, arranging for additional staff through local home health agencies and providing 

financial incentives to critical staff for working during a disaster. One participant explained his 

facility’s strategy: 

There’s probably five or six facilities within 10 miles of ours. One of the things we are 

working on... is trading of staff. If some of their staff live closer to our facility and can’t 

make it to theirs, ‘Come to ours, bring your family to ours, and we will put you to work!’ 

If some of our staff live closer to theirs, ‘Go there. Bring your family there.’ We are 

trying to make it as comfortable and easy as possible for the staff to come in. 

In responding to questions about roles that their nursing homes could potentially play in an 

emergency, focus group participants emphasized that their ability to provide resources and 

services to the community would be highly dependent on staffing. According to one participant, 

“Even in a good situation (in which) you have full staff, there’s not excess capacity to, to triage, 

to do many other things. Unless people came, you know, unless there were additional staff that 

would be mobilized...” 

In addition to the concerns about staff adequacy during a time of crisis, some nursing homes 

mentioned that State regulations on the number of hours that clinical staff can work 

consecutively would be problematic in an emergency. Participants expressed differing levels of 

confidence that such regulations would be relaxed in a disaster. 

Nursing homes are worried about running out of pharmaceutical and other medical 

supplies in a disaster. Nursing homes typically receive medication deliveries on a cyclical 

basis. Monthly delivery cycles appeared to be the norm. Hence, the length of time that they 

could sustain on their existing medication supplies would be highly dependent on when the 

disaster occurred in relation to their last delivery. One participant explained, “If you’re right at 

the end of the month and waiting for your medications to come in, oh boy, you’re in trouble.” 

While most nursing homes mentioned keeping emergency medication supplies including 

antibiotics and narcotics on-hand, they explained that these supplies would not last long. Many 

18 
participants described stockpiling medications as a desirable solution, but a number of issues 

associated with doing so were raised including rules against stockpiling, the high cost of 

obtaining large quantities of medication at a time, reimbursement issues, and concerns about 

security if the community became aware that they had such supplies. According to one 

participant, “We can’t stockpile medications. We have to get rid of them. As much as I would 

like to for a disaster, we can’t do it.” 

Participants stressed that the adequacy of medications and medical supplies must be taken 

into account when considering the potential roles that nursing homes might play in disasters. If, 

for example, nursing homes are asked to provide first aid or to care for patients transferred from 

acute care facilities, this will have a major impact on how long their limited supplies last. Many 

participants expressed concerns about the ramifications of running out of medications and 

medical supplies to care for their residents due to using them to provide care for people from the 

community or other facilities. 

The adequacy of fuel supplies to power the generators is a major concern because 

power serves a number of important functions in these facilities. All nursing homes reported 

having generators to provide back-up power in the event that their facilities lose electricity. 

When asked how long they would be able to power their generators without receiving additional 

fuel from outside sources, participants’ responses ranged from less than a day to seven days. 

While nearly all nursing homes reported performing period checks of their generator’s 

functioning, the generator often only powered a portion of the facility during the checks. This 

makes it difficult to predict the rate at which their fuel supplies would be exhausted if the whole 

facility were relying on the generator’s power. Another source of anxiety is whether or not the 

generator is strong enough to handle the full load of the facility. One participant told the group 

that her staff had been warned at a seminar that: 

When they run the generators on the full load for more than a day, most of them give out 

because they’re not used to it.

One participant told the group that she is worried that the fuel they use during periodic 

checks of the generator’s functioning will mean that they would not have enough left if an actual 

emergency occurred because they perform checks monthly, but only refuel once every three 

months. 

Participants reported a variety of problems associated with generator failure. Power is 

needed to maintain acceptable environmental conditions in the facilities. Nursing homes may be 

forced to transfer their residents elsewhere if they are without heat or air conditioning for an 

extended period of time during certain parts of the year. One participant articulated the 

difficulties in deciding what temperature warrants undertaking the challenges associated with 

evacuation: 

When you’ve got 150 residents and you’re thinking about moving them all when the 

temperature gets to...That’s a killer. We make it 86 degrees and we decide to move, but 

that’s as high as it ever goes and everybody is comfortable...I have residents who think 

90 is a good temperature. 

19 
Power is also necessary to keep some types of special equipment specific to this population 

going for a sustained period of time. For example, oxygen is used for some of the special beds in 

these facilities. In the absence of power, oxygen can be provided to patients that need it through 

portable oxygen tanks in lieu of the special beds. However, focus group participants stressed 

that portable oxygen only lasts a very limited time. One participant indicated that battery backup is now available for “some, but not all” of the medical equipment. 

Due to incontinence issues that are common with the geriatric population, laundry facilities 

are crucial. One participant pointed out that many facilities may not have even thought to ensure 

that their washing machines are hooked up to the generator. Without regular changes of soiled 

clothing and bed sheets, some patients would begin to experience skin breakdown and other such 

issues. Also, sanitation could become a problem. 

Nursing homes are concerned about having sufficient food and water supplies. Most 

nursing homes indicated that they could be self-sustaining on their existing food and water 

supplies for a period of about three days. While some nursing homes indicated that they store 

enough food and water to be self-sustaining for longer periods, a number of facilities indicated 

that their storage space is extremely limited. Given their space restrictions, storing extra supplies 

(above and beyond what the State requires) simply wouldn’t be possible for them. To alleviate 

this problem, a few facilities distribute water and food supplies to residents for storage in their 

rooms. 

When their existing supplies are depleted, these nursing homes will be in competition with 

the rest of the community to obtain more. Perceptions of whether a priority list for the 

replenishment of supplies exists and if so, where nursing homes would fall on such a priority list 

varied among focus group participants. According to one participant, “If a disaster is somewhat 

orderly, then it was stated that there might be some priority to supplies. But, probably not.” 

Another participant indicated that, “We do have a three-day supply. Anything after that, we 

would be pretty much competing with everybody else who wanted to get water. But, I think we 

are kind of high on the list.” 

3.3 Potential Roles of Nursing Homes 

Nursing homes represented are willing to accept residents from area hospitals but 

voiced concerns about patient acuity and facility capacity and staffing. Nearly all focus 

group participants reported that they would be able to accommodate their residents if area 

hospitals needed to discharge them after an emergency. One participant remarked, “I think 

[accepting former residents] would be the appropriate thing to do at that point in time...If I 

thought it was safe, I’d put them back in my rooms...we’d figure out a way to do it.” Several 

facilities also acknowledged that area hospitals would ask them to take patients that had not been 

former residents. Most of these facilities agreed they would do what they could to accommodate 

those patients. One participant remarked, “...we would need to say ‘yes’ to the hospitals to help 

them discharge those we could care for...That’s a role we would play.” Other participants had 

similar sentiments: 

20 
The hospitals know where our facility is...they know the size of our facility. We know 

we’ll be overrun with people coming and going from the hospitals because we’re right 

there. We have no doubt about that. 

When we had a tornado, the surrounding hospitals did call us up and we were set up to 

receive their less critical patients that were on their way to being discharged anyway. So 

we gave so many beds that we would take their patients. We’re certainly willing to do 

that...take people that are on the verge of being discharged from the hospital. 

All participants agreed that their ability to accept transfers depends on patients’ level of 

acuity and the level of care required. Focus group participants said that most nursing homes do 

not have the staff or equipment to care for high acuity patients or patients with certain 

conditions, which is why these patients were hospitalized: 

I would think we could handle the numbers, but it would depend on what acute care they 

were needing...These were people we couldn’t handle in an SNF, some we could take 

back, and some we couldn’t provide the care to keep them alive. 

If their needs were something I could attend to...it would depend on what their needs 

were at that time. 

Focus group participants explained that many nursing facilities specialize in caring for 

patients with certain conditions, such as Alzheimer’s, ventilator dependency, or cognitive 

impairment. Several participants remarked that they could not accommodate patients with 

certain conditions while several facilities stated they would simply not be able to accept high 

acuity patients. According to a couple of participants, “Our facility couldn’t take ventilator 

patients.” However, other facilities were willing to accept higher acuity patients from hospitals 

because they have specialized staff and skills to care for individuals with more complex 

conditions. Focus group participants suggested that area hospitals wanting to transfer residents 

would need to know “not just where our facility is, but what we are skilled in.” 

One concern voiced by several facilities was figuring out “who do you let in” especially in 

the case of bioterrorist or infectious agents. Participants did not want to place their residents at 

risk by accepting potentially infected individuals from outside the facility. According to one 

participant, “We would be prepared to take back people we’ve sent ...But if we have a bioagent 

or pandemic flu and it’s not in the building yet...if we take somebody back, we risk exposing 

other people and we’d say we can’t do that.” 

Adequacy of staffing was a major concern voiced by all the facilities during the focus 

groups. Facilities were concerned that they would not have enough staff to care for their 

residents, much less potential transfers from area hospitals, in the aftermath of a disaster. 

According to one participant: 

Our nursing staff is very stretched; we expect a lot of them. We could certainly receive 

patients from hospitals but I don’t think we would be able to offer care to them because it 

takes all our resources to take care of the residents we have. 

21 
Many participants were concerned that staff would not be able to reach the facility or would 

not want to leave their families to come to work. One participant remarked, “I would be 

concerned about staff...people are going to want to stay home and take care of their families.” 

Focus group participants also shared a concern that staff members would leave work in order to 

attend to their families, even though most facilities have policies restricting staff from leaving: 

Technically they [the staff] should not leave the facility. But in the middle of a disaster 

how many are going to be trying to get to their own families? How many really won’t 

leave? 

Several participants suggested that hospitals would need to transfer residents with the 

supplies and staff they needed in order to ensure that properly trained individuals could provide 

care to higher acuity patients: 

We would not want to take on a lot of acutely ill patients that would prevent us from 

providing care to our own residents...we are not staffed or equipped to care for acutely 

ill patients...You want to help as much as you can, but then do you dilute the care you are 

able to provide for your own people? 

Most facilities expressed concern about bed availability, though several suggested 

resourceful ways to create more beds should they become necessary. A few facilities 

represented would have significant problems accepting transfers because they run at or near full 

capacity most of the year: “My main limitation would be beds available. I am a 32 bed facility, 

and usually run 30-31 beds full. It just depends on time of year.” Several other facilities 

suggested they could create makeshift beds by placing mattresses in hallways. One participant 

remarked, “We would need to scrunch people into the building... put mattresses down the 

hallway, put blankets in the lobby.” 

Participants from facilities located in earthquake-prone regions (California, Washington, and 

Oregon) voiced concerns about accepting patients if their facility had sustained structural 

damage. Several participants in these States remarked they would need the building inspected 

before accepting additional patients: “If the DHS came out and gave us the okay, if the building 

was okay, then we could accept more patients.” A few participants felt their ability to accept 

patients would be a judgment call at the time of the disaster, even if their facility sustained 

damage. One participant said he would fit people into the buildings that had not sustained 

damage rather than trying to transfer all his residents out. 

Participants in one State were particularly concerned about the paperwork surrounding 

transferred residents. They assumed that the electronic medical record system would not 

function in the aftermath of a disaster and did not know how patient information and 

billing/reimbursement would be handled. They were concerned whether patients would be 

transferred with their original records and if they could recoup the costs of patient care. 

Nursing homes could provide basic medical care to outside patients. Most focus group 

participants suggested their facilities have the staff, supplies, and equipment available to provide 

22 
basic medical care to community members. One participant remarked that people see nursing 

homes as “a pseudo-hospital” and expected community members to “try to get in the door” of 

her facility if they could not get to area hospitals for medical care. Many participants across 

several of the focus groups agreed with this statement. A few participants reported that the 

American Red Cross expected their facilities to provide first aid: “The Red Cross told us that 

they’d expect us to do first aid...and then move them out.” Several participants reported being 

approached by their local emergency service agency and told they would be asked to “take on 

people from the community” and provide first aid “at a minimum” during an emergency. Most 

participants agreed their staff could administer vaccinations or medications without detracting 

from the care of their residents: “We have staff that could administer vaccinations and 

medications and that would be a community service that could be provided without necessarily 

having people move in to your facility”. 

Many participants suggested their staff could help triage patients even if they could not 

admit them. Most facilities hold special staff trainings in proper triage techniques and include a 

section on triage in their emergency manuals. One participant noted: 

I could see nursing homes being good triage areas...we are really well equipped to act in 

that manner. But I don’t think any of our facilities would be able to accommodate large 

scale acute patient flows. 

The question of morgue facilities was brought up independently in three of the six focus 

groups. Concern was expressed about dealing with deceased residents since transporting them to 

the county morgue would be problematic during an emergency. One participant reported that the 

local emergency services agency requested the use of her facility’s basement for that purpose: 

“We have a basement and that basement could be a morgue. Although I’m not sure how that 

would happen because it’s not cold down there.” 

Nursing homes could provide short-term shelter for community residents. Most focus 

group participants reported that their facilities have space to provide shelter for community 

members but expressed some concerns about providing food and other medical supplies without 

taking resources from their residents. Participants cited a wide range of spaces available for 

shelter: therapy rooms, dining rooms, conference rooms and recreation areas. One facility had 

an auditorium they planned to use in the event of an emergency. Several facilities also suggested 

local disaster relief agencies could use their grounds: “Next to our facility we have two huge 

fields...that would be the perfect space for a Red Cross facility”. 

Participants in nearly all the focus groups discussed how to prioritize care for residents, 

staff, families of staff and members of the general population who come seeking shelter. Several 

participants remarked that facility staff and their families would receive first priority for shelter. 

According to one participant, “If we have any large areas it would go to our staff...and then the 

greater community”. 

Nursing homes have little excess space and should not be used to store equipment or 

stockpile drugs. Nearly all focus group participants agreed that nursing facilities do not have a 

great deal of excess space and could not provide long term storage facilities for supplies. One 

23 
participant noted, “I’m sure we could allocate an area if we’re not using it for something 

else...but as far as open areas, we really don’t have an excess of storage.” Another participant 

reported that older facilities were particularly pressed for storage space: 

I’ve never had a building with excess space. There’s so many things that we’d like to 

have room for that we don’t have because of space issues...a true skilled facility, 

especially one that was built 40 years ago, you just don’t have enough space.

Participants noted that all nursing facilities have large areas that are routinely used by 

nursing home residents for activities such as watching television, playing games, dining or arts 

and crafts. Allocating this space for storage would mean “taking space away from a designated 

use.” Many participants suggested that their facility could provide some short term storage 

should local emergency response agencies require storage. 

When participants were asked about using nursing homes to stockpile pharmaceuticals, 

participants in nearly all focus groups expressed concern about security. Most facilities agreed 

that they would have space for stockpiled drugs but that doing so would require a facility to 

“designate a guard for that room, too,” because if the space stored pharmaceuticals, they would 

have to be able to lock and guard it. This theme came up repeatedly: 

There’s a problem with stockpiling...If people know that you have a stockpile, are you 

going to be able to maintain that stockpile? Security is going to be an issue...nursing 

homes are vulnerable. 

I think we have the capacity to do it. The thing that would scare me is the security to do 

that. We don’t have the manpower in our buildings to produce a secure environment. In 

a disaster people are going to want to care for their families...and they don’t care where 

they get it...What scares me about my building, even with the drugs I have on hand, is 

how do you secure that? 

Overall, the majority of participants agreed that nursing homes were not the appropriate 

place to store supplies, due to a lack of long-term storage facilities, but could provide some short 

term storage capacity for local disaster relief agencies. In addition, most participants felt that 

nursing home facilities should not be used to stockpile pharmaceuticals, despite having space 

available, because they could not keep the drugs secure. 

Participants from one focus group felt strongly that nursing homes should not play a 

large role in disaster response. The participants were fairly adamant that nursing homes are 

not equipped to participate in disaster response or recovery activities. According to one 

participant, “...a nursing home historically is not part of any disaster plan...when you think of 

disaster plans, the community’s number one resource is the hospital. Nursing homes are really 

not part of that equation.” Reasons participants gave for this perception included nursing home 

size, absence of doctors at the sites, and unreliable staff. Several participants suggested that 

nursing home staff were prone to the mass hysteria surrounding a disaster and would not be a 

reliable source of support or care for residents: “It’s every man for himself.” 

24 
Two participants added interesting caveats regarding the role of rural nursing homes 

facilities. One participant from a rural area felt that nursing homes could have an important role 

in disaster response activities in areas with very few hospitals and several large nursing homes. 

However, he emphasized that, to date, “These efforts are not coordinated”. This point was 

reiterated by another participant in a different focus group. She suggested that nursing homes 

would not be seen as area resources in metropolitan regions, but would be more likely play a role 

in a disaster in more rural areas.

3.4 Influence of State Regulations on Nursing Homes 

Participants were largely unaware of State regulations governing nursing homes 

during an emergency. Nearly all focus group participants did not know if regulations 

governing nursing homes during an emergency existed in their State. Many participants assumed 

that regulations would be “suspended or loosened” during an emergency, but were not sure if 

there were legislated rules or regulations to that effect. One participant recommended that “the 

State...let LTC facilities know what their stance would be in the case of a disaster.” Another 

participant expressed a similar concern: 

One of the fears we have is that the regulations say we can only put 2 patients in a 2 bed 

room. I’m only licensed for 162 patients, if I have 165 patients in my building...what 

really is the result from that? Are they going to look the other way?...Nobody had come 

back to us and said under these circumstances these are the rules 

Several participants suggested that bed licensure or staffing issues would not deter them 

from providing needed care during an emergency. According to one participant, “I would cast 

aside...the regulations for that period of time to accommodate those who are really in need.” 

Participants from the Oregon focus group said that nursing homes had only recently been 

involved in State disaster preparedness and planning activities. They all expressed concern about 

the lack of directives from the State but agreed that no one was going to “suspend the 

requirements of taking care of their own residents.” According to one participant, changes to 

regulations governing nursing homes during a disaster had not yet been made but: 

We just started talking about the suspension of rules and regulations in the event of a 

disaster where we don’t have the capacity to take in any more residents...If it’s not 

written right into the regulations that that stuff gets set aside, it’s going to be a real 

concern. 

In North Carolina, several participants knew that bed licensure regulations are waived if the 

Governor declares a state of emergency, though one facility was unaware of this regulation. In 

addition, the North Carolina nursing home association “applies to the State Department of 

Facility Services on behalf of the facilities” in order to get pre-approval if there is a hurricane 

warning or some other event. Participants stressed that nursing staff “would still be an issue” 

because nurses cannot work more than a 16 hour shift and this law “is not exempted in a 

disaster.” 

25 
Nursing homes need formal guidance as well as resources and money to develop 

disaster plans. Several participants expressed concerns that involving their nursing facilities in 

disaster preparedness and response activities would require them to develop comprehensive 

plans for their facilities. All participants agreed that nursing homes do not have the time, staff, 

training, knowledge, or resources to develop such a plan. One participant suggest that “If 

regulations are developed that require nursing homes to develop bioterrorism preparedness plans, 

then resources -- money, documents, consultations -- should be available to assist us in 

developing those plans.” This theme was reiterated across several focus groups. Several 

participants said they simply do not have time to do comprehensive disaster planning or “train 

and drill staff” once a plan is developed. According to one participant: 

We’ve all had disaster plans for decades because it’s been required. In light of Katrina 

and bioterrorism there’s this big push, and to be honest I’m feeling overwhelmed because 

there’s basically no resources. I have a business to run and now I have to put a lot of 

extra time into something I know nothing about...and everybody’s starting to change 

their expectations -- from the State to the fire marshall who are also getting pressure 

from the Feds. 

Several other participants stated they do not have people on staff knowledgeable in disaster 

planning and coordination nor do they have the money to hire outside consultants to assist them. 

In light of this lack of knowledgeable people, many participants indicated a need for “some level 

of government” to provide them with guidelines related to handling contamination during a 

bioterrorist event or infectious disease outbreak because it would be “too hard to develop plans 

around this with no experience and limited resources”. 

3.5 The Role of the Red Cross and the Effects of Hurricane Katrina 

Nursing homes are uncertain about the role of the Red Cross in a disaster. The role of 

the Red Cross was discussed in the majority of the focus groups. Focus group participants 

universally described the Red Cross as a valuable organization. A few facilities mentioned 

having worked with them to train/certify their staff on CPR and first aid procedures or to provide 

community first aid in their facilities. One facility that had previously been unsuccessful in 

working with its local government in emergency planning ultimately sought coordination with 

other entities and received a very helpful response from the Red Cross. 

It became clear that most nursing homes do not plan on getting needed support from the Red 

Cross during an emergency. According to one participant: 

The Red Cross and community support is probably not going to be focused on nursing 

homes because they are going to assume that [we] have more resources than the rest of 

the community to take care of ourselves. There is going to be such a rationing of support 

if there is a major disaster that I wouldn’t expect that the Red Cross would be helping out 

nursing homes. 

Not only did participants not expect help from the Red Cross, some nursing homes are 

concerned that they may be asked to provide support to the Red Cross. One participant that had 

26 
recently learned that the Red Cross had been dedicated a large space on their property to 

establish a shelter in an emergency had the following to say: 

They’re not there for our benefit. They are still asking that we be able to defend in place 

or work through the needs that we have. They may ask us to help augment them. Like, 

maybe if we have a couple of nurses that can help with triage or nursing wounds...not 

helping us. They would be asking us for someone to come over and assist in something. 

Several participants in this focus group agreed that the Red Cross would not provide support 

to nursing homes and may actually seek their help. Another facility in a different State also 

reported having space on their campus designated as a potential Red Cross shelter. Participants 

in that State’s group voiced concerns that their local Red Cross is failing financially, resulting in 

staff and office reductions. 

Hurricane Katrina provoked fears of liability and judgment, decreased confidence that 

the government will be a source of support in an emergency, and resulted in changes to the 

duration of time for which nursing homes think they need to be self-sustaining in an 

emergency. In the two focus groups that were held after Hurricane Katrina, fears of being 

judged for their actions during a disaster were pervasive: 

I think the biggest fear is that we will try to do everything right, but if we fail...we’ll be 

judged...we’ll be on the front page of the news...In my heart, I believe that a lot of those 

folks down in Katrina did everything they could. It’s so easy to judge after the fact how 

things were done wrong when there are no resources to provide assistance to do things 

right. 

Everybody has a fear of how, not so much the government responds to you, but how the 

political situation and press respond to you...We have created an environment...either 

you did wonderful and you are a hero or you did terrible and you are a goat. ...A lot of 

people are very fearful of any kind of disaster for this very reason. 

In addition to judgment from the political and media realms, a number of participants were 

worried about being held liable for their actions in a disaster because the United States has 

become such a “litigation society:” 

Sometimes, too, you get really caught up in the regulations and legality part to the point 

that you are paralyzed...You can go a little bit overboard. 

There’s a little flexibility, but I think it could create a lot of hesitancy to do certain things 

if we’re concerned that when this is all over, somebody will be unhappy about what we 

did, we’ll get sued, or we’ll lose our license... 

So much of what we are judged on is our documentation. In a disaster, does that go out 

the window?...I wonder about the folks that were in Katrina and how they handled that. 

The litigation that’s going on now really isn’t fair if they weren’t able to document 

everything that they were doing like they would in a normal day. 

27 
At one of these two post-Katrina focus group sites, there was a prevailing lack of confidence 

that the government would be there to help their facilities during an emergency. They voiced the 

expectation that they will have to “fend for themselves”. One participant added: 

I don’t think it’s realistic that they’re going to be there at the door to help us. Even if they 

choose to be and want to be...It’s not that they don’t want to be. They just can’t be 

everywhere. 

Participants in one State explained that Hurricane Katrina had prompted them to take steps 

to increase the amount of time for which they could be self-sufficient in an emergency. 

According to one participant: 

The residents aren’t going anywhere. They need patient care. You try to provide that the 

best you can for a 72 hour minimum period...Nowadays, when we do disaster 

preparedness, we’re training to be prepared for 7 days. For a skilled nursing facility, 

that’s going to be hard to do. Your shelves are only so big for food. Keep an open mind 

that it may be more than 72 hours. That’s the reality...That is directly a result from 

Katrina. Everything changed after Katrina. Everything went to 7 immediately. 

28 
Section 4. Conclusions 

This study can help fill gaps in our knowledge about the role nursing homes could play in 

larger local or regional preparedness efforts. In addition, the study reveals many concerns 

specific to nursing homes and the populations they serve that should be addressed if these 

facilities are expected to provide resources to the community during and after a public health 

emergency. 

Based on our findings from the six focus groups, nursing homes have prepared for natural 

disasters but have given very little thought to bioterrorism. Facilities reported having disaster 

plans in place, some more comprehensive than others, and reviewing these plans with nursing 

staff at orientation and during regular in-service trainings. Disaster plans appeared to focus on 

the natural disasters most prevalent in a region (e.g. wild fires, earthquakes, floods, hurricanes). 

Only a few facilities reported including policies and procedures specific to bioterrorism in their 

disaster plans. All the facilities we spoke with reported quarterly fire drills and annual or semiannual disaster drills. These drills were held in accordance with State requirements, suggesting 

that States may need to require more comprehensive drills that address bioterrorism if this is 

deemed important. However, focus group participants stressed that, if States do develop new 

requirements related to bioterrorism, it will be important to provide resources, including 

guidance documents, training, staff, and money, to their facilities so they could develop viable 

plans. 

Results from the focus groups also highlight the differing levels of local coordination of 

disaster planning across States. Two States initiated focus groups or forums to discuss local 

coordination to which nursing homes and other long-term care facilities were invited. 

Participants reported varying levels of success with these activities, but they indicate that some 

States are actively trying to involve nursing homes in coordination efforts. Other participants 

reported no success in trying to engage local emergency planning agencies in disaster planning. 

Most participants lacked a basic understanding of State regulations that govern nursing homes 

during an emergency. While a few participants (mostly those directly engaged in the local 

government) were aware of bed licensure or staffing regulations in a state of emergency, most 

were not. This lack of knowledge suggests that State nursing home associations or other 

regulatory bodies may need to be more proactive in informing nursing home facilities of changes 

in regulations during an emergency. 

Focus group participants expressed a wide range of needs, some of which were unique to 

nursing home facilities and some which would be problematic to a variety of health facilities. 

Participants voiced concerns about caring for special patient populations that require specialized 

equipment or nursing care during an emergency. In particular, participants were concerned 

about patients with Alzheimer’s and other cognitive impairments. Many facilities caring for 

these patients have locked facilities with high-tech monitoring systems that could easily fail 

during power loss. Participants also were concerned about the logistical difficulties involved in 

moving or evacuating patients with limited physical abilities. Focus group participants stressed 

the importance of maintaining a calm, routine environment to avoid undue stress on their elderly 

patients. Linked to these concerns about patient care were concerns about staffing. Participants 

29 
were concerned about maintaining staffing levels since nursing staff would undoubtedly want to 

care for their own families or may have difficulty getting to work. 

Several concerns raised by focus group participants may be of concern to the larger health 

care community. These include: 

• Maintaining adequate pharmaceutical and medical supplies 

• The ability of generators to support an entire facility and the adequacy of fuel supplies 

• Feeding the resident population and keeping them adequately hydrated. 

Most participants reported that pharmaceuticals and medical supplies are delivered on 

monthly cycles. Thus, the amount of time they could sustain their resident population on 

existing medical supplies is highly dependent on when the disaster occurred in relation to their 

last delivery. While all nursing home facilities represented have generators to provide back-up 

power, many participants were concerned that the generator would not be able to power the 

entire facility. Nursing home populations are particularly sensitive to heat and cold, so the 

environmental conditions regulated by generators are particularly important. 

Finally, the focus group results suggest a number of potential roles nursing homes could play 

in the event of a public health emergency. Nearly all participants reported they could accept 

transferred residents back from area hospitals to free up bed space in those facilities. Most 

facilities acknowledged the possibility of receiving additional patients from the community and 

were willing to accommodate those patients if they could. In doing so, however, they had two 

major concerns: patient acuity and staffing. Focus group participants agreed that their ability to 

accept transfers or patients from the community depended on the patient’s level of acuity. They 

explained that many facilities specialize in caring for patients with certain conditions. Thus, one 

facility might be able to take a transferred ventilator patient while another could not. This 

suggests that area hospitals wanting to transfer patients would need to know what the nursing 

homes in their area were skilled in. Participants also stressed that they would need staff with the 

knowledge and expertise in providing care to higher acuity patients if they were to accept them. 

Nursing homes could provide a variety of additional resources during an emergency, 

including basic medical care and short term shelter. Participants agreed that nursing staff had the 

skills to provide a certain level of medical care to outside community members. They suggested 

staff could provide vaccinations, basic first aid, or triage services. Many larger facilities felt they 

could use their facilities’ community spaces, such as dining rooms and auditoriums, to provide 

short-term shelter. However, long-term storage of equipment and stockpiled drugs was 

considered an inappropriate use of facilities. Providing long-term storage would require nursing 

homes to take space designated for specific activities away from the resident population. 

30 

Focus groups are valuable in that they provide very detailed information about a small 

sample of nursing homes and have high face validity. However, because of the relatively small 

number of nursing homes we talked with, our data do not allow us to generalize these 

conclusions to all nursing homes in the United States. We can, however, conclude that nursing 

homes have special patient populations that require disaster plans that address the needs of their 

residents. Nursing homes can also provide valuable resources to their communities if they are 

included in local and regional disaster planning activities. 
References 

CDC, 2004. National Nursing Home Survey: 2004 Facility Tables. Available online: 

http://www.cdc.gov/nchs/data/nnhsd/nursinghomefacilities2006.pdf#01. 

Dosa DM, Samsonov ME, Nace DA. A pilot study investigating bioterrorism preparedness in 

area nursing homes. JAGS. 2003;51(S4): S117. 

Helget V, Smith PW. Bioterrorism preparedness: a survey of Nebraska health care institutions. 

Ame J Infect Control. 2002;30:46-48. 

Institute of Medicine (IOM). Preparing for Terrorism: Tools for Evaluating the Metropolitan 

Medical Response System. FJ Manning and L Goldfrank (eds), Washington, DC: National

Academy Press. 2002. 

Maxwell JA. Qualitative Research Design, An Interactive Approach. Thousand Oaks, CA: Sage 

Publications. 1996. 

Morgan DL and Krueger RA. The Focus Group Kit. Thousand Oaks, CA: Sage Publications. 

1998. 

Saliba D, Buchanan J, Kington RS. Function and response of nursing facilities during 

community disaster. Am J Public Health. 2004;94(8): 1436-1441. 

Spillman BC, Lubitz J. New estimates of lifetime nursing home use: have patterns of use 

changed? Medical Care. 2002;40(10): 965-975. 

31 
Appendix A. Focus Group Moderator’s Guide 

32 
Introductory Remarks 

• Brief Project Overview: RTI is a leading non-profit research organization located in 

Research Triangle Park, North Carolina. We have a contract with the AHRQ to explore 

the role and special needs of nursing homes in planning and response in the event of a 

disaster. 

• Staff introductions...

• Review general rules of focus group operation and data capture: 

o One person talks at a time, speaking clearly to facilitate note taking 

o Using first names only 

o Facilitator will attempt to be sure everyone has a chance to respond to all 

questions 

• Privacy and confidentiality assurance. Exempted from informed consent by RTI IRB; 

data only reported in the aggregate without revealing the names of any focus group 

participants or their affiliated nursing home 

• Questions from participants? 

Discussion Questions 

1. Has your nursing home thought about the impact of bioterrorism or other public 

health emergencies on your facility? 

Probe: Has anyone from your facility been involved in any State/local bioterrorism 

planning activities? 

2. Has your facility done any planning or training specifically for bioterrorism or 

other public health emergencies? Please describe... 

Probes: What about planning and training for natural/man-made disasters (e.g., fires, 

floods)? Do you have a disaster plan? Do you do regular drills? 

3. In the event of a terrorist attack or other public health emergency, what are your 

principle concerns regarding your facility and continued service for your residents? 

In other words, do you have special needs that we should know about? 

Probes: Water loss, sewer or power outage, natural gas leaks, food supplies, issues 

around quarantine or needs of special patient populations (e.g., Alzheimer’s). Also, with 

respect to staffing, getting staff there and keeping them there in light of their own 

personal family responsibilities. 

33 
34 

4. What role, if any, do you envision your facility playing in disaster response or 

recovery? 

Probe: Augmented capacity for local hospitals (i.e., beds; converting to a quarantine 

facility); trained staff to assist with local response such as giving vaccinations; gear and 

pharmaceutical supply storage. 

5. Would you be prepared to receive a rapid influx of transferred residents back from 

acute care facilities in your area? 

--note patient transfers usually take many hours with lots of required paperwork; patients 

may be transferred back at a higher level of acuity than would be the case normally; and 

there are likely transport issues. 

6. How long could your facility be self-sustaining without external supply of water and 

food, medical supplies, pharmaceutical therapeutics, electric power? 

Probes: Do they have food/water stores? Are these mandated by the State? Do they 

have a generator? Do they have back-up plans? Do they have experience with natural 

disasters (earthquakes, fires, floods)? 

7. How do State regulations influence the ability of nursing homes to offer support 

and/or surge capacity in the event of bioterrorism or other public health 

emergency? 

Probes: If the governor of your State declared a state of emergency, would you have 

concerns about bed licensure limits and/or nurse shift limits? 

8. Take a look at this survey and try to complete it as best you can, marking those 

questions you know you would have an answer for with a “Y” and those you would 

not be able to answer even with more time with a “DK.” Any questions that you feel 

are not applicable, please mark “NA.” Additional comments or observations can be 

made directly on this copy. 

9. What do we need to let State and Federal governments know about nursing homes 

and their ability to function in a time of disaster? 

10. Is there anything we haven’t asked you about that would be good for us to know as 

we attempt to explore the role and special needs of nursing homes in preparedness 

planning? 

Probe: Administrators from other States have mentioned the role of the Red Cross. 

Would the Red Cross be a key resource for your facility in a disaster? 
Appendix B. Model Long-Term Care Preparedness Needs Assessment 

This needs assessment is an example of the kind of survey that can be used either by planners surveying long

within their jurisdictions or by facilities as an aid to assessing their own emergency preparedness. We recommen

facility staff to complete and review all the survey elements. 

For planners administering this assessment, it is recommended that a confidentiality statement/disclaimer be included, 

maintain the confidentiality of each respondent’s data. The information will be summarized for statewide and regional planare no foreseeable risks to individual facilities. Individual facility data will not be published and the identification requested 

be used only for ensuring response. Thank you for your participation in this survey. 

NOTE: AHRQ is offering this questionnaire as a model only. AHRQ is not administering this question

be collecting data compiled from it. Please do not send completed questionnaires or compiled data to AHR

35
Model Long-term Care Preparedness Needs Assessment 

Name of Nursing Facility: Provider Number:

City: County:

Who is Facility’s Key Contact for Emergency Preparedness? 

FAX or email completed survey to: Questions about the survey should be directed to: FAX number here. Address here.NO LATER THAN: ******* 

TEL #: FAX #: Email:

36
A. General Information 

A1 Please provide the name of your facility: A2 Please list your nearest hospital:A3 Please identify the county or locality that your facility resides in: 

  < 1 mile  5-10 miles 

A4 How far is your facility from the nearest hospital with emergency services?  1-5 miles  >10 miles A5 How many hospitals (on average) do you refer patients to? Number_________________ 

Please describe the primary affiliation of your facility (Check all that applies)? 

A6 

Faith Based 



Secular 



For Profit 



Non-Profit

 



Chain 



A7 Does your facility have a contingency plan (or procedure) for giving or receiving mutual aid/support to/from: (check 

 A local or state emergency planning agency 

 A neighboring hospital or hospital system 

 Another nursing home or nursing home consortium 

 Other community health providers (home health, physicians’ offices) 

 Do not have such an agreement 

A8 

Do you perceive your facility as having a formal role in a community/state/federal response to an emergency situation such as a hurricane or pandemic flu situation 



Yes 

No 

Not Sure 

Do you perceive bioterrorism as a potential concern in your region? Yes No Not Sure A9 If yes, on a scale of 1 (not likely) to 10 (exceedingly likely), how likely do you think a bioterrorist threat is to your region? __________ (Scale 1 to 10) 
A. General Information 

Does your facility budget financial resources to 

A10 preparedness for a disaster or mass casualty incident? Yes No 

IF YOU ANSWERED NO TO A10; SKIP TO QUESTION A13. OTHERWISE CONTINUE TO A11:

Provide an estimate of your facility’s expenditures in preparation for a disaster or mass casualty incide

Estimated emergency preparedness expenditures for the A11 $__________________ last 12 months

A12 For which of the following activities has the facility incurred expenditures over the last 12 month period? (check all t



training and disaster exercises increased pharmaceuticals 



enhanced security housekeeping 



staffing reorganization equipment purchases 



protocols and plans upgraded communication 



physical plant changes Other: 



upgraded computerized IT systems 



inter-institutional arrangements 

Estimated emergency preparedness expenditures for the A13 $__________________ next 12 months

A14 For which of the following activities does the facility expect to incur expenses over the next 12 month period? (chec



training and disaster exercises increased pharmaceuticals 



enhanced security housekeeping and other stocks 



staffing reorganization equipment purchases 



protocols and plans upgraded communication 



physical plant changes Other: 



upgraded informational systems 



inter-institutional arrangements 

A15 Does your facility maintain a vendor contract with a transportation company to provide for emergency evacuation? 



Yes 

No 



CONTINUE TO SECTION B. 

38
B: Facility Specifics 

  

B1 Bed Category Current Census Licensed B

(# patients) (# patients

Skilled Nursing Care 

Assisted Living Beds 

Other 

For each of the above bed categories, indicate:  The facility’s current census  The number of licensed beds 

Yes  B2 Does your facility have isolation or reverse ventilation rooms? Don’t Know  No  

B3 If yes, how many isolation rooms are there? Number ______________ 

CONTINUE TO SECTION C. 

39
C. Vaccination Status 

C1 Does your facility keep records on resident vaccination status?  Yes  No C2 Does your facility maintain records on employee vaccination status?  Yes  No 

How many staff members regularly give vaccinations? C3 Number: ______________ (e.g. Giving intramuscular or subcutaneous injections) Does your facility provide vaccination to all eligible patients against C4 pneumonia (pneumovax)?  Yes  No If yes, what percentage of patients is vaccinated against pneumonia (pneumovax)? C5 Number_________% (Percentage)Does your facility provide vaccination to all eligible clients/patients C6 against influenza (flu)?  Yes  No If yes, what percentage of patients is vaccinated against influenza (flu)? C7 Number_________% (Percentage)Does your facility provide vaccination against influenza (flu) to all C8 eligible employees?  Yes  No 

C9 If yes, what percentage of employees is vaccinated against influenza? Number_________% (Percentage) 

 Lack of interest by facility  La

fa

C10 

 Lack of interest by employees  La

em

What barriers do you perceive contribute to or prevent complete 

vaccination of staff against influenza? (Check all that apply) 

 Cost of vaccination  O

In case of emergency, would your facility be willing to provide C11 vaccination services to the community?  Yes  No 

CONTINUE TO SECTION D. 

40
D. Physical Plant and Operations Support 

D1 Does your facility have a generator for providing emergency power?  Yes  No (Go to qD2 How long could your facility supply emergency power? Hours = ____________________

Does your generator control all electrical circuits (including AC, oxygen D3 generators)  Yes  No 

 Lights  Air Conditio

D4  Computer  Oxygen If no, does your generator fail to control 

 Kitchen  Refrigeratio

Does your facility have one or multiple ventilation systems for the D5 building?  One  Multiple Does your facility have internal capabilities for Food Preparation D6 or do you rely on an external food distributor?  Internal  External Does your facility maintain emergency rations in case food delivery cannot be D7 made?  Yes  No 

D8 If no, how many days rations does your facility maintain for each patient Number of days______________D9 Does your facility have the ability to filter your own water?  Yes  No  Don

D10 Does your facility maintain bottled water in case of emergency?  Yes  No  DonD11 If yes, how many days of bottled water does your facility have on hand? Number of days______________

CONTINUE TO SECTION E. 

41
E. Emergency Plan 

Does your facility have an emergency plan for use in case of natural 

E1 disaster, act of terrorism, or infectious disease emergency?  Yes  No  Don’t Know 

IF NO PLEASE SKIP TO SECTION FHas your facility’s emergency plan been reviewed by state or local officials? E2  Yes  No  Don’t Know Does the emergency plan call for an on-site designated command center? E3  Yes  No  Don’t Know 

If yes, does the command center have access to . . . (check all that apply)  Radio  Internet

E4  2-Way Radio  TV, Local 

 NOAA Radio  TV, Cable  Telephone  Satellite  Multiple Phone lines  Video Conferencing 

E5 In case of an emergency (after calling 911) who is your facility’s first contact? 

 Medical Director  Administrative Director  Nursing Director  911 or external source  Other 

List:_______________________ 

Does the facility’s emergency plan address the following .......? 

E6 Evacuation planning?  Yes  No E7 Isolation of infected patients?  Yes  No 

42
E8 Triage of casualties?  Yes  No

E9 Quarantine?  Yes  No 

E10 Decontamination?  Yes  No E11 Contingency for power failure?  Yes  No 

Reconfiguration of facility space for quarantine of communicable E12 diseases and treatment of infectious disease epidemics?  Yes  No 

E13 Transfer of multiple or mass casualties?  Yes  No 

Credentialing, orientation and supervision of clinicians not normally working in facility responding to a bioterrorism event or infectious disease outbreak? 

E14  Yes  No E15 Mechanisms to manage unsolicited clinical help and donated items?  Yes  No E16 An abbreviated patient registration process for disaster victims?  Yes  No 

A process for identifying and incorporating spokespersons and/or E17 subject matter experts to provide information to the media?  Yes  No A process for sharing patient information and/or victim’s lists with other E18 hospitals/providers/public agencies?  Yes  No 

E19 If yes, is the process . . . (select one)

 Computer-based, using internet/email connection to distribute  Paper-based, using fax/courier/runners to distribute  Other  Not Applicable 

E20 Coordination with Local or Regional Hospitals  Yes  NoE21 Coordination with Local or State Emergency Planning Agencies  Yes  NoE22 Coordination with Red Cross/ Local Relief Agencies  Yes  No 

CONTINUE TO SECTION F. 

43
F. Bioterrorism Readiness & Training 

F1 Does the facility have a system in place for early recognition of patients exposed to . . . (check all that apply)

 Biological agents  Radiological agents  None of these Chemical agents  Nuclear agents Does the facility have a system in place for training staff in the care of contaminated patients . . . (check all that app

F2  Biological  Radiological  None of these 

 Chemical  Nuclear 

F3 Does the facility have annual safety education that includes training to facility employees on . . . (check all that appl

 Bioterrorism  Radiological Disaster  Weapons of Mass Destruction  Nuclear Disaster  Chemical Contamination  None of these Infectious Disease Outbreak 

F4 Does the facility have general orientation that includes training to new facility employees on . . . (check all that apply

 Bioterrorism  Radiological Disaster  Weapons of Mass Destruction  Nuclear Disaster  Chemical Contamination  None of these Infectious Disease Outbreak 

CONTINUE TO SECTION G. 

44
G. Exercises & Drills 

Which of the following exercises or drills (actual or staged), whether held at the facility or elsewhere, have staff participated 

past 12 months? (check all that apply) 

Definitions: Table Top= Simulations or Classroom exercises Facility Drills= Actual exercises at your facility Community Drills= Exercises run by area hospitals or community organizations Real Event= An actual real life occurrence

A C 

Table Top B Commun

(or Class Room) 

Exercises 

Facility Drills Wide Dri

G1 Mass Casualty    G2 Chemical    G3 Biological    G4 Radiological    G5 Nuclear    G6 Bomb Threat or Terrorist Threat    G7 Evacuation Drills    

Utility Failures: telephone, water, G8 electric, computer, sewer, HVAC, etc.    

G9 Hostage/Barricade    

G10 Extreme Weather (Hurricane ,etc.)    G12 Has the facility conducted drills during the following times or under the following circumstances? (check all that app

 Day shift (7AM-3PM)  Night Shift (11PM-7AM)  Evening Shift (3PM-11PM)  Weekend (Saturday, Sunday) 

Within the last 3 years, has the facility performed a staff recall to determine the number of staff who could report to work in the event of an emergency? 

G13  Yes  No

CONTINUE TO SECTION H. 

45
H. Pharmaceutical Stockpile 

H1 Does your facility keep stocks of antibiotics on site for  Yes  No  Don’t Know 

emergency use? Does your facility keep Intravenous (IV) fluids on site for emergency use? H2  Yes  No  Don’t Know Does your facility maintain oxygen on site for emergency use? H3  Yes  No  Don’t Know Does your facility maintain respiratory bronchodilators (albuterol nebulizers) on site for emergency use? H4  Yes  No  Don’t Know 

I. Logistics, Facilities, and Security 

I1 Does your facility require all staff to wear ID badges  Yes  No I2 Are the facility’s security staff . . . (check all that apply)

 Facility-Employed  Contracted  Facility does not have security staff (If so, skip to Section K)

I3 Is the facility’s Security Department staffed 24/7?  Yes  No 

Does the facility have a procedure in place to lock down all exterior doors within 30 minutes, without requiring “outside” personnel? (If no, skip to Section K)

I4  Yes  No 

I5 The lock down procedure includes notification of . . . (check all that apply)

 Personnel in the building  Area hospitals  Fire, Police, and EMS  Medical Director/Administration 

CONTINUE TO SECTION J. 

46
J. Distributed Learning Capability 

J1 Does your facility have a computer with Internet access?  Yes  No 

If yes, please estimate the number of computers with Internet access J2 Number_________________ 

J3 How are the facility’s PCs connected to the Internet? (check all that apply)

 Dial Up  Dedicated T1/ISDN  High Speed (DSL/Cable)  Combination of above 

J4 Which of the following people have access to computers with internet access (check all that apply)

 Administrator  Nursing Director  Physicians  Medical Director  Staff RN’s  Patients  Billing Staff  Staff LPN’s  Other (Please list) _______________

J5 Does your facility provide employees with e-mail access?  Yes  No J6 Does the facility have video-conferencing capability?  Yes  No J7 Does the facility have a fax machine?  Yes  No

Does the facility have a “Power safe” emergency phone? J8  Yes  No (i.e. a phone that does not require electrical power) 

J9 Facility computers can be used for which of the following? (check all that apply) 

 E-mail  Looking up labs reports  MDS Entry   Looking up radiology reports  Electronic Order Entry Web Access  Care Plan Access  Documentation (H&Ps)  MAR (medication) use 

CONTINUE TO SECTION K. 

47
Indicate the facility’s priorities in getting financial or other training/education or technical assistance for emergency prepare

scale where 1 indicates highest priority and 5 indicates lowest priority. It is important to distinguish higher priority from not mark all items “Highest Priority.” 

 TE

K. Priority Checklist FINANCIAL TRAININ

Highest Lowest Highest 

Preparedness Category Priority 

1 2 3 4 

Priority Priority 

5 1 2 

Implementing an Emergency Incident K1 Command System        Conducting or Participating in Emergency K2 Exercises        

K3 Training Staff in Emergency Procedures        

Diagnosis & Treatment of Victims of K4 Chemical Agents        Diagnosis & Treatment of Victims of K5 Biological Agents        Diagnosis & Treatment of Victims of K6 Radiological Agents        

K7 Evacuation Planning (during storms,etc.)        

Staff/Family Protection (vaccination, K8 logistical arrangements, etc.)        Regional Planning with Other Institutions, such as Red Cross, EMAs, or Other Government Agencies 

K9        

K10 Formalizing Mutual Aid Agreements        

48
 TE

K. Priority Checklist FINANCIAL TRAININ

Highest Lowest Highest 

Preparedness Category Priority 

1 2 3 4 

Priority Priority 

5 1 2 

K11 Enhancing Patient Care Surge Capacity        

Selecting and Purchasing Personal K12 Protective Equipment (PPE)        

K13 Upgrading Respiratory Isolation Capacity        K14 Upgrading Emergency Power Capability        

Other Physical Plant Improvements 

K15 (list below and rate): 

A        B        

C        

Increasing Emergency Stockpiles of K16 Medications and Other Supplies        

K17 Upgrading Communications Equipment        K18 Upgrading Security Arrangements        

PROCEED TO NEXT PAGE. 

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COMMENTS: 

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Thank you for participating in the 

Long Term Care Emergency Preparedness Needs Assessment.

50