Topic Collection Cover Page

Emergency Operations Plans/ Emergency Management Program
Topic Collection
December 12, 2024

Topic Collection: Emergency Operations Plans/ Emergency Management Program

There is a sizeable body of evidence that supports planning for hazards, threats, and events that may impact access to, or the delivery of, healthcare services in a community. Each state has different requirements for healthcare organizations to ensure that they are properly planning for emergencies. The emergency management program (EMP) should detail how the facility implements the emergency management principles of mitigation, preparedness, response and recovery and the personnel, authorities, and other details of program administration. Healthcare system planners must ensure that their EMP accounts for the current and changing landscape of requirements, regulations, threats, and hazards. Complying with standards and following programs (EMP) will help healthcare entities reliably respond to and recover from disasters, as well as work cohesively and effectively with emergency management partners.

The emergency operations plan (EOP) details what the facility or agency will DO during a disaster (incident command implementation, command center location and activities, specific plans by department, etc.). This plan should be developed as an all-hazards plan, and must integrate with local EOPs and coalition plans for information sharing and resource requests. Individual plans may also include specialty annexes for incidents such as burn, chemical, pediatric, or infectious disease (access the Plans, Tools, and Templates section in the rest of our Topic Collections for examples).

The resources in this Topic Collection highlight select standards, guidance, regulation, accreditation programs, and tools that can help healthcare emergency preparedness professionals create, or bolster the foundation of existing, programs and plans. Due to the interdependencies between, and reliance upon strong EOPs within EMPs, resources for both are provided in this Topic Collection. Resources are listed in separate sub-categories as appropriate. Though this Topic Collection is focused on healthcare, a limited number of public health agency plans are also included as resources in support of program and plan integration across partners. Access the Incident Management and Coalition Response Operations Topic Collections for more resources (particularly as coalition constructs and related documents can be a critical component of the EOP concept of operations).

Each resource in this Topic Collection is placed into one or more of the following categories (click on the category name to be taken directly to that set of resources). Resources marked with an asterisk (*) appear in more than one category.

Must Reads


Administration for Strategic Preparedness and Response. (2016). Health Care Preparedness and Response Capabilities for Health Care Coalitions. U.S. Department of Health and Human Services.
This 70-page document describes the four capabilities that healthcare coalitions and individual healthcare facilities need to prepare for, respond to, and recover from emergencies. The capabilities are: foundation for healthcare and medical readiness; healthcare and medical response coordination; continuity of healthcare service delivery; and medical surge. For example, Capability 1, Objective 4 covers training and preparing the healthcare and medical workforce (Objective 4, Activities 3-5 also contain specific information about exercises within the HPP program) and Capability 3, Objective 7 is focused on coordinating healthcare delivery system recovery.
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Administration for Strategic Preparedness and Response. (2024). Department of Health and Human Services All-Hazards Plan. U.S. Department of Health and Human Services.
This U.S. Department of Health and Human Services emergency operations plan describes coordinated departmental management of response to and recovery from disasters and public health emergencies (PHE) in response to requests for assistance or when the situation requires federal emergency human services or social services capabilities. It provides an all-discipline, all-hazards approach to establish a comprehensive framework for coordinated federal public health, medical, human services, and social services assistance to support STT governments’ response activities directed at saving and sustaining lives and protecting or restoring human health in response to and recovery from natural or human-caused disasters or PHE.
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American College of Emergency Physicians. (n.d.). Hospital Disaster Preparedness Self-Assessment Tool. (Accessed 9/5/2024.) California Hospital Association.
This detailed checklist assessment can help hospital staff review their emergency operations plan components. This tool includes information on categories that should be considered in a post-disaster assessment (particularly sections 3-7).
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ASPR TRACIE. (2023). CMS and Disasters: Resources at Your Fingertips. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response.
The Centers for Medicare & Medicaid Services issued the Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers Final Rule to establish consistency for healthcare providers participating in Medicare and Medicaid, increase patient safety during emergencies, and establish a more coordinated response to natural and human-caused disasters. This document provides links to numerous related resources applicable to a variety of providers and suppliers.
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Centers for Disease Control and Prevention (2012). Hospital All-Hazards Self-Assessment (HAH).
This resource is a PDF of a tool designed to help assess and identify potential gaps in a facility's all-hazards emergency plan. The tool is designed for hospital preparedness staff, including planners, administrators, and others. (Note that this resource pre-dates the Centers for Medicare & Medicaid Services Emergency Preparedness Rule of 2016, and so may not be in alignment with it.)
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Emergency Medical Services County of Los Angeles. (n.d.). Los Angeles County Disaster Preparedness Resource Guide for Long-Term Care Health Facilities. (Accessed 9/5/2024.)
This emergency operations plan guide and template were designed for Long-Term Care Health Facilities and can be customized by the user. It includes sections on: (1) foundational knowledge; (2) planning resources; and (3) Disaster Response Checklist, which provides 13 key Hazard-specific plans on pages 27-48. (Note that this guide and template were created prior to the release of the 2016 Centers for Medicare & Medicaid Services [CMS] Emergency Preparedness [EP] Rule, which planners should reference to ensure compliance for their organizations.)
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FEMA’s CPG 101 provides guidelines on developing whole community emergency operations plans (EOPs) and includes best practices and suggestions for plan development. This quintessential guidance document can be leveraged by healthcare emergency planners as they create, update, or revise planning documents.
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McNeal, M., Daniels, E., Akintobi, T.H., et al. (n.d.). Emergency Preparedness Toolkit for Primary Care Providers. (Accessed 9/5/2024.) Morehouse School of Medicine.
This planning guide is meant for medical practices and can help emergency planners enhance practice readiness, planning, and response for emergencies and disasters, which will assist communities in the aftermath of an event. The toolkit includes fact sheets, templates, trainings, and other resources and links to references.
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National Fire Protection Association. (2019). NFPA 1600: Standard on Disaster/Emergency Management and Business Continuity Programs. (Requires free registration.)
This document is a national standard for emergency management/business continuity programs.
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National Nurse-Led Care Consortium. (2019). Health Center Emergency Management Plan Template.
Health center staff can use this template to create and customize their own emergency operations plans, compliant with the Centers for Medicare & Medicaid Services Emergency Preparedness Rule. After completion of the free registration, the web page provides access to two comprehensive templates: (1) Health Center Emergency Management Plan and (2) NNCC Communications Plan.
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The Institute for Crisis, Disaster, and Risk Management at the George Washington University. (2010). Emergency Management Principles and Practices for Health Care Systems, 2nd Edition. U.S. Department of Veterans Affairs.
These free online trainings include five units that describe key principles in healthcare emergency management. Units include: Emergency Management Program; Incident Command System, Multiagency Coordination System, and the Application of Strategic NIMS Principles; Healthcare System Emergency Response and Recovery; and Emergency Management System Evaluation and Organizational Learning for Healthcare Systems.
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U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. (2016). Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers.
This rule establishes consistent emergency preparedness requirements for health care providers participating in Medicare and Medicaid, increases patient safety during emergencies, and establishes a more coordinated response to natural and man-made disasters.
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University of Toledo Medical Center. (2019). University of Toledo Medical Center Emergency Operations Plan.
This is an emergency operations plan for an academic medical center that may be referenced and adapted for use by other facilities. Note that this document uses color codes as opposed to plain English, and also contains elements pertaining to the Emergency Management Program (EMP), and users may wish to separate that information out when adapting this plan.
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World Health Organization. (2011). Hospital Emergency Response Checklist.
This tool is structured according to nine key components, each with a list of priority actions to support hospital managers and emergency planners in achieving: (1) continuity of essential services; (2) well-coordinated implementation of hospital operations at every level; (3) clear and accurate internal and external communication; (4) swift adaptation to increased demands; (5) the effective use of scarce resources; and (6) a safe environment for healthcare workers.
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Yale New Haven Health System, Center for Emergency Preparedness and Disaster Response. (2017). CMS Emergency Preparedness Final Rule Crosswalk.
This crosswalk was created by (YNHHS-CEPDR), in collaboration with a number of national subject matter experts. Emergency and disaster related program, policy, communication, training and exercise elements of regulatory and accreditation standards were mapped to the CMS Emergency Preparedness Conditions of Participation. Every effort was made to ensure that the mapped regulations and accreditation standards matched as closely as possible. However, this document should be used only as a resource for reviewing and updating healthcare emergency preparedness plans and does not replace existing federal, local, or association guidance.
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Evaluation


* Administration for Strategic Preparedness and Response. (2023). ASPR RISC 2.0 User Instructions. U.S. Department of Health and Human Services.
This manual guides users through the second version of the Risk Identification and Site Criticality Toolkit, designed to help healthcare and public health organizations identify threats and hazards and assess the vulnerabilities of their facilities and communities. Access the related video here: https://risc.mitre.org/training/
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American College of Emergency Physicians. (n.d.). Hospital Disaster Preparedness Self-Assessment Tool. (Accessed 9/5/2024.) California Hospital Association.
This detailed checklist assessment can help hospital staff review their emergency operations plan components. This tool includes information on categories that should be considered in a post-disaster assessment (particularly sections 3-7).
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Centers for Disease Control and Prevention (2012). Hospital All-Hazards Self-Assessment (HAH).
This resource is a PDF of a tool designed to help assess and identify potential gaps in a facility's all-hazards emergency plan. The tool is designed for hospital preparedness staff, including planners, administrators, and others. (Note that this resource pre-dates the Centers for Medicare & Medicaid Services Emergency Preparedness Rule of 2016, and so may not be in alignment with it.)
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Lynch, T. and Cox, P. (2006). Reverse Quality Management: Developing Evidence-based Best Practices in Health Emergency Management. Quality Management in Health Care. 15(2): 104-115.
This article is a review of best practices for governmental accountability in health emergency management based on the British Columbia Ministry of Health Framework for Core Functions in Public Health. The fieldwork was conducted in the fall of 2005 between hurricane Katrina and the South Asia earthquake.
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Education and Training


Center for Domestic Preparedness. (n.d.). Framework for Healthcare Emergency Management. (Accessed 9/5/2024.) Federal Emergency Management Agency.
Emergency healthcare providers and planners can learn about development, implementation, maintenance, and administration of emergency management programs and plans for healthcare facilities. The course includes lectures and guided discussions on topics such as emergency management issues for healthcare, personal protective equipment, decontamination, and isolation and quarantine.
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Federal Emergency Management Agency. (2015). IS-235.C: Emergency Planning.
This five hour-long independent study course covers the basics of the emergency planning process and emergency operations plans and is geared towards “all individuals involved in crisis and emergency management decision making.”
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University of Arizona, Mountain West Preparedness and Emergency Response Learning Center (MWPERLC). (n.d.). Emergency Management Readiness Series. (Free registration necessary; accessed 9/5/2024.)
This introductory-level series consists of four courses that explain the importance of advanced planning to ensure a robust emergency response. Topics include: how to conduct a hazard vulnerability analysis/risk assessment; the steps taken to develop a comprehensive all-hazards emergency operations plan (EOP); the importance of planning for disruptions to normal operating procedures during a disaster covered by a continuity of operations plan; and Emergency Operations Center (EOC) Management.
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Event-Specific Lessons Learned


The speakers in this symposium highlight how the healthcare emergency preparedness field has changed in the 20 years following the 9/11 attacks. Key figures and graphics are shared separately on this webpage.
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Rose, D., Murthy, S., Brooks, J., and Bryant, J. (2017). The Evolution of Public Health Emergency Management as a Field of Practice. American Journal of Public Health.
The authors explain how the field of public health emergency management has changed in recent years to adapt to infectious disease outbreaks, natural disasters, industrial and environmental catastrophes, and conflict.
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United States Senate. (2018). Sheltering in Danger.
This report details findings from an investigation into the negative effects of the 2017 hurricane season on nursing homes and assisted living facilities. Part VI lists specific recommendations these types of facilities can take into consideration to improve emergency preparedness.
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Vesely, R. and Hoppszallern, S. (2014). 2014 Emergency Management Survey. Health Facilities Management.
The authors examine emergency management programs in healthcare facilities and discuss the types of events that have required emergency plan activation, equipment stockpiles, facility changes, and most common advanced emergency program features.
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Guidance/Guidelines


Administration for Strategic Preparedness and Response. (2016). Health Care Preparedness and Response Capabilities for Health Care Coalitions. U.S. Department of Health and Human Services.
This 70-page document describes the four capabilities that healthcare coalitions and individual healthcare facilities need to prepare for, respond to, and recover from emergencies. The capabilities are: foundation for healthcare and medical readiness; healthcare and medical response coordination; continuity of healthcare service delivery; and medical surge. For example, Capability 1, Objective 4 covers training and preparing the healthcare and medical workforce (Objective 4, Activities 3-5 also contain specific information about exercises within the HPP program) and Capability 3, Objective 7 is focused on coordinating healthcare delivery system recovery.
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ASPR TRACIE. (2023). CMS and Disasters: Resources at Your Fingertips. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response.
The Centers for Medicare & Medicaid Services issued the Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers Final Rule to establish consistency for healthcare providers participating in Medicare and Medicaid, increase patient safety during emergencies, and establish a more coordinated response to natural and human-caused disasters. This document provides links to numerous related resources applicable to a variety of providers and suppliers.
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Association of Healthcare Emergency Preparedness Professionals. (2014). HICS (Hospital Incident Command System) for Small Hospitals.
This resource provides links to guidance and templates that can help smaller hospitals implement the Hospital Incident Command System.
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Backer, H., Smiley, D., Schoenthal, L. et al. (2014). Hospital Incident Command System (HICS) Guidebook: Fifth Edition, May 2014. California Emergency Medical Services Authority.
This latest version of the HICS guidebook meets the needs of all types of hospitals, regardless of location, size, or patient care capabilities and provides event-based templates and resources in addition to the system framework and job action sheet templates. Specifying the ICS used and how it is implemented is a key component of the EOP.
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* California Association of Health Facilities. (n.d.). Emergency Operations Plans. (Accessed 9/5/2024.)
This webpage provides links to several resources that support planning for long-term care facilities, including an Emergency Operations Plan (EOP) template; facility profile sheet; plan evaluation checklist; and template for a letter to inform family members of residents of emergency plans.
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California Emergency Medical Services Authority. (2014). Hospital Incident Command System.
This website provides access to the Hospital Incident Command System (HICS) 2014 Guidebook, HICS forms and Job Aids.
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California Emergency Medical Services Authority. (2014). Hospital Incident Command System.
This website provides access to the Hospital Incident Command System (HICS) 2014 Guidebook, HICS forms and Job Aids.
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Emergency Management Accreditation Program. (2019). The Emergency Management Standard.
The Emergency Management Accreditation Program (EMAP) is an independent non-profit organization, fosters excellence and accountability in emergency management programs, by establishing credible standards applied in a peer review accreditation process.
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  • Brendan McCluskey The standard is free to access and provides the foundation for what a "good" emergency management program (whether based in HPH or otherwise) should be doing.
    8/12/2015 8:45:13 AM
FEMA’s CPG 101 provides guidelines on developing whole community emergency operations plans (EOPs) and includes best practices and suggestions for plan development. This quintessential guidance document can be leveraged by healthcare emergency planners as they create, update, or revise planning documents.
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This handbook can help homecare providers develop emergency plans. It also features New York-specific state regulations and resources.
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Lessons Learned Information Sharing. (n.d.). Best Practice. Emergency Management Programs for Healthcare Facilities: Program Organization. (Accessed 9/5/2024.) U.S. Department of Homeland Security, Federal Emergency Management Agency.
This document provides an overview of the managerial roles and responsibilities for a healthcare facility’s emergency management program. It also emphasizess that an emergency management program should typically be managed by one individual, while a committee should provide guidance and overall direction for the program.
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This handbook was created to assist Michigan home care agencies in writing, augmenting, and evaluating their emergency preparedness plans, based on best practices. The document provides guidance for assessing the strength of preparedness plans; an in-depth discussion of plan development; and tools for ongoing evaluation of a plan's effectiveness.
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National Association of Community Health Centers. (n.d.). Developing and Implementing an Emergency Management Plan for Your Health Center. (Accessed 9/5/2024.)
This webpage bulletin describes why health centers need to develop emergency operations plans, and also provides guidance on the planning process and plan content and links to related resources.
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National Fire Protection Association. (2018). NFPA 99: Health Care Facilities Code.
This standard establishes fire, explosion, and electrical risk criteria for healthcare services or systems regarding patients, staff, or visitors in healthcare facilities.
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* National Fire Protection Association. (2019). NFPA 1600: Standard on Disaster/Emergency Management and Business Continuity Programs. (Requires free registration.)
This document is a national standard for emergency management/business continuity programs.
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The Institute for Crisis, Disaster, and Risk Management at the George Washington University. (2010). Emergency Management Principles and Practices for Health Care Systems, 2nd Edition. U.S. Department of Veterans Affairs.
These free online trainings include five units that describe key principles in healthcare emergency management. Units include: Emergency Management Program; Incident Command System, Multiagency Coordination System, and the Application of Strategic NIMS Principles; Healthcare System Emergency Response and Recovery; and Emergency Management System Evaluation and Organizational Learning for Healthcare Systems.
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The Joint Commission. (2019). Emergency Management in Health Care: An All-Hazards Approach, Fourth Edition. (Available for purchase.)
This publication (available for purchase) can help health care organizations through all aspects of emergency management planning, from conducting a hazard vulnerability analysis and developing an emergency operations plan (EOP), through recovery.
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The Joint Commission. (2020). Emergency Management Resources.
The Joint Commission Emergency Management standards provide the baseline for which healthcare facilities seeking accreditation should prepare. This webpage includes links to case studies and other resources that can help facility staff adhere to standards (which are available at a cost to the user).
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Users can follow this link to learn more about The Joint Commission's new and revised emergency management chapter standards effective July 2022 for all accredited critical access hospitals and hospitals.
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This proposed rule requires Medicare- and Medicaid-participating providers and suppliers to plan for both natural and human-caused disasters, and coordinate with federal, state, tribal, regional, and local emergency preparedness systems. It also requires that these providers prepare to meet needs of patients, clients, residents, and program participants during disasters and emergency situations.
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U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. (2012). Healthcare Preparedness Capabilities: National Guidance for Healthcare System Preparedness: January 2012.
This guidance from the Office of the Assistant Secretary for Preparedness and Response identifies the eight capabilities (aligned with the Public Health Preparedness capabilities) that serve as the basis for healthcare system, coalition, and organization preparedness: Materials in Capability 3—Emergency Operations Coordination— can particularly help with the writing of facility and coalition Emergency Operations Plans.
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U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. (2015). NIMS Implementation for Healthcare Organizations Guidance.
Healthcare organization emergency planners can use the guidance in this document to ensure their emergency operations plans are in alignment with the National Incident Management System. (Please note that the most current version of NIMS is dated 2017 and is available here: https://www.fema.gov/media-library-data/1508151197225-ced8c60378c3936adb92c1a3ee6f6564/FINAL_NIMS_2017.pdf.)
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VanVactor, J. (2012). Strategic Health Care Logistics Planning in Emergency Management. (Free registration required.) Disaster Prevention and Management. 21(3): 299-309.
The author explains how logistics are related to healthcare disaster preparedness and emergency readiness. He emphasizes the importance of a sound logistics platform when it comes to healthcare organization disaster preparedness.
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Plans, Tools, and Templates (EMP)


* Administration for Strategic Preparedness and Response. (2023). ASPR RISC 2.0 User Instructions. U.S. Department of Health and Human Services.
This manual guides users through the second version of the Risk Identification and Site Criticality Toolkit, designed to help healthcare and public health organizations identify threats and hazards and assess the vulnerabilities of their facilities and communities. Access the related video here: https://risc.mitre.org/training/
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* Administration for Strategic Preparedness and Response. (2023). RISC Toolkit 2.0. U.S. Department of Health and Human Services.
The Risk Identification and Site Criticality (RISC) Toolkit is an objective, data-driven all-hazards risk assessment that can be used by public and private organizations within the Healthcare and Public Health Sector to inform emergency preparedness planning, risk management activities, and resource investments. The RISC Toolkit provides owners/operators in the HPH Sector with nationally recognized standards-based evaluation criteria in an easy-to-follow, guided format. It can be utilized by a wide variety of HPH stakeholders including but not limited to hospitals, long-term care facilities, community health centers, health care coalitions, and public health agencies.
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  • Tony Barker Great tool that has very effective resource links. Makes the HVA process evidence based and provides an excellent format for use. Thank you to the development team!
    12/12/2018 12:56:37 PM
American Hospital Association. (n.d.). Model Hospital Mutual Aid Memorandum of Understanding. (Accessed 9/5/2024.)
Memoranda of Understanding are considered one of the most common cooperative arrangements for healthcare facilities in disasters. This model template can be used by those facilities looking for a way to address resource sharing with neighboring facilities as part of their EOP.
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ASPR TRACIE. (2024). ASPR TRACIE Evaluation of Hazard Vulnerability Assessment Tools. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response.
This comparison chart shows the similarities and differences among the primary hazard vulnerability assessment (HVA) tools used by public health and health care organizations, and the Federal Emergency Management Agency’s Threat and Hazard Identification Risk Assessment (THIRA). Each description includes a summary of its primary use/purpose, as well as information on who developed the tool and how, the format of the tool, the calculations approach, and the benefits and limitations of the tool.
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California Hospital Association. (2011). Hospital Emergency Management Program Checklist.
This tool provides guidance for hospitals regarding the components included in an emergency management program.
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Community Healthcare Association of New York State, Primary Care Emergency Preparedness Network. (n.d.). Development Planning and Compliance Checklist for FQHCs. (Accessed 9/5/2024.) New York City Department of Health and Mental Hygiene.
This checklist may be used as a guide to determine whether your health center's emergency management program contains all the required elements within the Centers for Medicare & Medicaid (CMS) Emergency Preparedness (EP) final rule.
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Federal Emergency Management Agency. (2019). Senior Leader Toolkit. U.S. Department of Homeland Security .
The documents on this webpage can help those in emergency management "brief newly elected or appointed senior leaders/executives on an organization’s emergency management program and on leaders’ responsibilities during an incident."
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McNeal, M., Daniels, E., Akintobi, T.H., et al. (n.d.). Emergency Preparedness Toolkit for Primary Care Providers. (Accessed 9/5/2024.) Morehouse School of Medicine.
This planning guide is meant for medical practices and can help emergency planners enhance practice readiness, planning, and response for emergencies and disasters, which will assist communities in the aftermath of an event. The toolkit includes fact sheets, templates, trainings, and other resources and links to references.
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This document provides Spectrum Health sites a framework to promote proactive risk and opportunity identification, analysis, evaluation, and treatment. This includes loss control and risk strategies that minimize adverse effect of loss and enhances opportunities within the operational, clinical, safety, human capital, reputational, strategic, financial, regulatory, technological, and hazard domains of the organization.
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This plan can help Spectrum Health sites meet their Emergency Preparedness Program objectives and lists roles and resources available for doing so. It can be used as a model for other health organizations.
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U.S. Department of Health and Human Services, Health Resources & Services Administration. (2016). Form 10: Emergency Preparedness Report.
This form, which is also part of the Health Resources & Services Administration’s Health Center Program Site Visit Guide, can be used by health centers when preparing their annual emergency preparedness and management reports. The form can also serve as a short checklist of emergency preparedness activities a health center should undertake.
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* Wisconsin Department of Health Services. (2018). CMS Emergency Preparedness Rule Toolkits.
This webpage includes links to toolkits and other resources designed to help certain types of healthcare facilities better understand the Centers for Medicare & Medicaid Services (CMS) Emergency Preparedness Rule. There is both a PDF (toolkit) and Word version (workbook) for each facility type, and the relevant CMS rules for each facility type are included. Each toolkit includes sample templates and planning worksheets that can help facilities develop compliant plans, policies, and procedures.
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World Health Organization. (2011). Hospital Emergency Response Checklist.
This tool is structured according to nine key components, each with a list of priority actions to support hospital managers and emergency planners in achieving: (1) continuity of essential services; (2) well-coordinated implementation of hospital operations at every level; (3) clear and accurate internal and external communication; (4) swift adaptation to increased demands; (5) the effective use of scarce resources; and (6) a safe environment for healthcare workers.
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Yale New Haven Health System, Center for Emergency Preparedness and Disaster Response. (2017). CMS Emergency Preparedness Final Rule Crosswalk.
This crosswalk was created by (YNHHS-CEPDR), in collaboration with a number of national subject matter experts. Emergency and disaster related program, policy, communication, training and exercise elements of regulatory and accreditation standards were mapped to the CMS Emergency Preparedness Conditions of Participation. Every effort was made to ensure that the mapped regulations and accreditation standards matched as closely as possible. However, this document should be used only as a resource for reviewing and updating healthcare emergency preparedness plans and does not replace existing federal, local, or association guidance.
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Plans, Tools, and Templates (EOP)


Administration for Strategic Preparedness and Response. (2021). National Health Security Strategy. U.S. Department of Health and Human Services.
The goal of the National Health Security Strategy (NHSS) is to strengthen and sustain communities’ abilities to prevent, protect against, mitigate the effects of, respond to, and recover from disasters and emergencies. This webpage includes links to the full text of the strategy, an overview, the NHSS Implementation Plan, the NHSS Evaluation of Progress, and an NHSS Archive.
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* Administration for Strategic Preparedness and Response. (2023). RISC Toolkit 2.0. U.S. Department of Health and Human Services.
The Risk Identification and Site Criticality (RISC) Toolkit is an objective, data-driven all-hazards risk assessment that can be used by public and private organizations within the Healthcare and Public Health Sector to inform emergency preparedness planning, risk management activities, and resource investments. The RISC Toolkit provides owners/operators in the HPH Sector with nationally recognized standards-based evaluation criteria in an easy-to-follow, guided format. It can be utilized by a wide variety of HPH stakeholders including but not limited to hospitals, long-term care facilities, community health centers, health care coalitions, and public health agencies.
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  • Tony Barker Great tool that has very effective resource links. Makes the HVA process evidence based and provides an excellent format for use. Thank you to the development team!
    12/12/2018 12:56:37 PM
Administration for Strategic Preparedness and Response. (2024). Department of Health and Human Services All-Hazards Plan. U.S. Department of Health and Human Services.
This U.S. Department of Health and Human Services emergency operations plan describes coordinated departmental management of response to and recovery from disasters and public health emergencies (PHE) in response to requests for assistance or when the situation requires federal emergency human services or social services capabilities. It provides an all-discipline, all-hazards approach to establish a comprehensive framework for coordinated federal public health, medical, human services, and social services assistance to support STT governments’ response activities directed at saving and sustaining lives and protecting or restoring human health in response to and recovery from natural or human-caused disasters or PHE.
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* California Association of Health Facilities. (n.d.). Emergency Operations Plans. (Accessed 9/5/2024.)
This webpage provides links to several resources that support planning for long-term care facilities, including an Emergency Operations Plan (EOP) template; facility profile sheet; plan evaluation checklist; and template for a letter to inform family members of residents of emergency plans.
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California Department of Public Health (CDPH) and the California Association of Health Facilities (CAHF). (2017). NHICS: Nursing Home Incident Command System. American Health Care Association.
This webpage includes information on the nursing home incident command system (NHICS), which can be used by facilities regardless of size or resident care capabilities, and is intended to assist with their emergency planning and response efforts for all hazards. Links to the NHICS guidebook, forms, response guides, Job Action Sheets (JAS), and training are included.
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California Emergency Medical Services Authority. (2015). Emergency Operations Plan.
This emergency operations plan template is designed for Skilled Nursing Facilities and can be customized by the user. It includes rapid response guides, a response concept of operations, and appendices that can help ensure continuity of operations. (Note that this template was created prior to the release of the 2016 Centers for Medicare & Medicaid Services [CMS] Emergency Preparedness [EP] Rule, which planners should reference to ensure compliance for their organizations.)
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This checklist supports activation of an Emergency Operations Plan (EOP) and may help with coordination of efforts and response involvement among hospitals, Health Care Coalition partners, emergency medical services, public health agencies, and environmental health departments. Topics include Activation, Assessment, Response Plans, and Resource Requests.
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Carr, M., Hammon, R., Glenn, J., et al. (2008). Emergency Preparedness Packet for Home Health Agencies. National Association for Home Care and Hospice.
This document contains templates and tools for the development of an all-hazards emergency preparedness plan to be used by home care and hospice providers.
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Colorado Department of Public Health and Environment. (n.d.). Emergency Preparedness Resources for Health Facilities. (Accessed 9/5/2024.)
This webpage includes links to “resources and information to help planning teams develop, implement and maintain emergency operations plans.” Included are a basic plan toolkit, hazard vulnerability analysis toolkit, and a mass care/mass casualty functional annex toolkit.
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Emergency Medical Services County of Los Angeles. (n.d.). Los Angeles County Disaster Preparedness Resource Guide for Long-Term Care Health Facilities. (Accessed 9/5/2024.)
This emergency operations plan guide and template were designed for Long-Term Care Health Facilities and can be customized by the user. It includes sections on: (1) foundational knowledge; (2) planning resources; and (3) Disaster Response Checklist, which provides 13 key Hazard-specific plans on pages 27-48. (Note that this guide and template were created prior to the release of the 2016 Centers for Medicare & Medicaid Services [CMS] Emergency Preparedness [EP] Rule, which planners should reference to ensure compliance for their organizations.)
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Fairfax County Office of Emergency Management. (2019). Fairfax County Emergency Operations Plan.
This multidisciplinary all-hazards plan establishes a comprehensive framework for the management of major emergencies and disasters within Fairfax County. It is comprised of a base plan, appendices, support annexes, and emergency support functions.
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Federal Emergency Management Agency, Incident Management Systems Integration Division. (2023). Acronyms, Abbreviations, and Terms: A Capability Assurance Job Aid.
Emergency planners can use the information contained in this guide to become more familiar with the various acronyms and terms used in the emergency management field.
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Florida Agency for Healthcare Administration. (n.d.). Current CEMP Forms. (Accessed 9/5/2024.)
This webpage includes links to various Florida-specific checklists and emergency plan templates for several provider types, including: nursing homes; homecare agencies; ambulatory surgery centers; hospices; hospitals; and others. These documents may be helpful to planners in developing their own emergency operations plans.
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Kansas Department of Health and Environment. (n.d.). Dialysis Facility Disaster Plan Template (DOC). (Accessed 9/5/2024.)
This is an emergency management plan template for chronic dialysis facilities in Kansas that may be adapted for other facilities. (Note that this template was created prior to the release of the 2016 Centers for Medicare & Medicaid Services [CMS] Emergency Preparedness [EP] Rule, which planners should reference to ensure compliance for their organizations.)
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Lee County, Florida, Emergency Management. (2014). CEMP Criteria for Ambulatory Surgery Centers.
This checklist contains the required elements for a comprehensive emergency management plan, as well as guidance on the plan format, for ambulatory surgery centers in Florida. It may be used as a reference by other facilities to help develop their plans. (Note that this checklist was created prior to the release of the 2016 Centers for Medicare & Medicaid Services [CMS] Emergency Preparedness [EP] Rule, which planners should reference to ensure compliance for their organizations.)
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Minnesota Department of Health. (2023). Minnesota Long-Term Care Preparedness Toolkit.
This toolkit was developed to assist with emergency preparedness planning for individuals requiring long-term care. It can be used by long-term care facility owners, administrators, and staff. This toolkit includes a discussion of the Incident Command System (ICS), HIPAA issues, sample templates, forms, and suggested resources to develop and/or enhance facility emergency preparedness plans.
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Mississippi State Department of Health. (n.d.). Mississippi State Department of Health-Facilities Preparedness. (Accessed 9/5/2024.)
This webpage links to emergency operations plan templates for: home health; hospice; hospitals; long-term care; and personal home care.
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National Nurse-Led Care Consortium. (2019). Health Center Emergency Management Plan Template.
Health center staff can use this template to create and customize their own emergency operations plans, compliant with the Centers for Medicare & Medicaid Services Emergency Preparedness Rule. After completion of the free registration, the web page provides access to two comprehensive templates: (1) Health Center Emergency Management Plan and (2) NNCC Communications Plan.
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Perry, R. and Lindell, M. (2006). Hospital Planning for Weapons of Mass Destruction Incidents. (Abstract only.) Journal of Postgraduate Medicine. 52(2):116-20.
This article is a result of a literature review that focused on six elements related to weapons of mass destruction incidents that must be addressed in hospital disaster plans: incident command, hospital security, patient surge, decontamination, mental health consequences, and communications.
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South Carolina Department of Health and Environmental Control. (2013). Emergency Operations Plan Development Guide and Template for Extended Care Facilities.
This South Carolina-focused template was developed to support emergency operations planning for licensed nursing or assisted living facilities. It includes base plan information, as well as a series of checklists for policies and procedures, and Job Action Sheet content. It may be referenced and customized by facilities, as appropriate. (Note that this template was created prior to the release of the 2016 Centers for Medicare & Medicaid Services [CMS] Emergency Preparedness [EP] Rule, which planners should reference to ensure compliance for their organizations.)
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Southeast Texas Regional Advisory Council. (2017). Healthcare Facility Emergency Operations Plan "Criteria Checklist".
This checklist can help facilities review existing plans, note planning gaps, specify policies and procedures, and establish a training and exercise program to ensure compliance with the Centers for Medicare & Medicaid Emergency Preparedness Rule.
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U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. (n.d.). Disaster Preparedness: A Guide for Chronic Dialysis Facilities. Second Edition. (Accessed 9/5/2024.) U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services.
This emergency operations plan manual includes templates that can be tailored to the needs of dialysis and end stage renal disease facilities.
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U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. (2013). Emergency Preparedness Checklist.
This checklist can be utilized by healthcare emergency planners to help aid in the development of emergency plans. (Note: this resource pre-dates the final Emergency Preparedness Rule.)
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University of Texas, Health Science Center at Houston. (2019). Emergency Plans.
This multi-hazard operations plan for a university specifies procedures staff can take in the Health Sciences complex to prevent, prepare for, respond to, and mitigate emergency situations in a safe, orderly and efficient manner. It may be used as a reference by other research and science facilities in the development of their emergency operations plans.
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  • Bridget Kanawati Thank you for informing us of the broken link. It appears the plan was updated in 2018. We have updated our records with the new URL.
    9/9/2019 10:19:55 AM
  • Kristina Long Link doesn't work
    9/8/2019 4:01:39 PM
University of Toledo Medical Center. (2019). University of Toledo Medical Center Emergency Operations Plan.
This is an emergency operations plan for an academic medical center that may be referenced and adapted for use by other facilities. Note that this document uses color codes as opposed to plain English, and also contains elements pertaining to the Emergency Management Program (EMP), and users may wish to separate that information out when adapting this plan.
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Vermont Agency of Human Services, Department of Disabilities, Aging, and Independent Living. (2010). Emergency Preparedness Planning for Nursing Homes and Residential Care Settings in Vermont.
This manual contains guidance, worksheets, and checklists that long-term care facilities may use to inform the development of their facility-specific emergency operations plans. The plan is scalable—based on a modified ICS structure for use—and provides the full ICS structure for larger facilities. It also incorporates continuity of operation elements. (Note that this manual was created prior to the release of the 2016 Centers for Medicare & Medicaid Services [CMS] Emergency Preparedness [EP] Rule, which planners should reference to ensure compliance for their organizations.)
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* Wisconsin Department of Health Services. (2018). CMS Emergency Preparedness Rule Toolkits.
This webpage includes links to toolkits and other resources designed to help certain types of healthcare facilities better understand the Centers for Medicare & Medicaid Services (CMS) Emergency Preparedness Rule. There is both a PDF (toolkit) and Word version (workbook) for each facility type, and the relevant CMS rules for each facility type are included. Each toolkit includes sample templates and planning worksheets that can help facilities develop compliant plans, policies, and procedures.
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Plans, Tools, and Templates (Public Health)


Arizona Department of Health Services. (2016). Emergency Response Plan.
This emergency operations plan describes how a state health department will manage responses to public health emergencies. It includes considerations for medical surge and mass fatality management, and how response operations will be coordinated among partners, including the healthcare community.
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This resource includes information to guide response actions of public health directors responsible for initiating the response to a public health emergency during the first 24 hours of an incident.
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Florida State Emergency Response Team. (2023). Public Health Emergency Management Plan. (Version 2.0). Florida Department of Health.
This all-hazards plan supports Florida’s State Comprehensive Emergency Management Plan. It is intended to be implemented during any emergency, incident or disaster that impacts the state’s public health and medical system.
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Frederick County Health Department. (2018). All Hazards Emergency Operations Plan.
This all-hazards emergency operations plan (EOP) for a county health department was written as a companion plan to the county EOP Health & Medical Services Annex. While it does not include operational annexes, it does focus on the health department’s role and responsibilities for all public health emergencies that affect the county.
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Hamilton County Public Health. (2018). Emergency Response Plan Basic Plan.
This resource is a comprehensive all-hazards emergency operations plan for a county health department. It also covers the delegation of power to local health departments starting on page 69. The plan contains a mix of EMP/EOP information.
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Merced County Department of Public Health. (2017). Medical / Health Emergency Operations Plan.
This EOP was developed to assist the Merced County (CA) Department of Public Health and other medical and health personnel throughout the county plan for, respond to, and recover from a natural disaster or human-caused event. It provides a framework for the Medical/Health Branch of the County’s Emergency Operations Center and the Departmental Operations Center of the Health Department. It is a support document to the Merced County Operational Area Emergency Operations Plan developed by the Merced County Office of Emergency Services and available at http://web2.co.merced.ca.us/boardagenda/2017/20170221Board/162451/162457/162519/162682/EOP162682.pdf.
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Minnesota Department of Health. (2019). All-Hazards Response and Recovery Plan-Base Plan.
This all-hazards emergency operations plan for a state health department includes response activities by activation level, and defines communication pathways among partners including how healthcare coalitions are integrated into response.
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San Diego County, Office of Emergency Management. (2022). Annex E: Public Health Operations.
Annex E is the EOP for San Diego County’s health department and is one of several departmental EOPs for the overall San Diego County Emergency Operations Plan, available at https://www.sandiegocounty.gov/content/sdc/oes/emergency_management/oes_jl_oparea.html
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South Carolina Department of Health and Environmental Control. (2019). Emergency Operations Plan.
This resource is an all-hazards emergency operations plan (EOP) for a state health agency. The tables that start on page 15 help identify specific tasks and responsibilities for this department and may be useful to others.
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Stanislaus County Health Services Agency. (2021). Public Health All-Hazards Emergency Operations Plan.
This all-hazards emergency operations plan describes how a county public health department in California will respond to emergencies. It includes sections on regional coordination, and roles and responsibilities of healthcare and EMS partners.
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Standards and Regulations


Emergency Management Accreditation Program. (2013). The Emergency Management Standard.
This document is geared towards state and local agencies and lists the 64 standards the Emergency Management Accreditation Program (EMAP) uses to evaluate programs. Although very few healthcare plans are EMAP-accredited, the standards can be helpful for self-evaluation.
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National Association of County and City Health Officials. (2016). Project Public Health Ready.
This training and recognition program (not actually a standard, but offers criterion-based assessment) measures local health department capacity and ability to plan for, respond to, and recover from public health emergencies. The resources on this webpage focus on standards for local preparedness planning and include links to crosswalk documents that highlight how this program aligns with other related national programs.
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* National Fire Protection Association. (2019). NFPA 1600: Standard on Disaster/Emergency Management and Business Continuity Programs. (Requires free registration.)
This document is a national standard for emergency management/business continuity programs.
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U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. (2016). Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers.
This rule establishes consistent emergency preparedness requirements for health care providers participating in Medicare and Medicaid, increases patient safety during emergencies, and establishes a more coordinated response to natural and man-made disasters.
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Agencies and Organizations


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California Hospital Association. Emergency Preparedness.
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National Association of Community Health Centers. National Association of Community Health Centers.
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The Joint Commission. Emergency Management Resources.
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U.S. Department of Homeland Security, Federal Emergency Management Agency. National Incident Management System (NIMS).
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