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Long-term Care Facilities
Topic Collection
October 9, 2023

Topic Collection: Long-term Care Facilities

Long-term care includes a range of support services that an individual may need to meet their personal care needs. Long-term care may be provided through home healthcare services, or in facilities, such as nursing homes, assisted living facilities, and continuing care retirement communities. Individuals needing long-term care may include the elderly, those with chronic health conditions, and individuals requiring short-term rehabilitation.

This Topic Collection addresses residential care facility issues including skilled nursing facilities and assisted living facilities. The Homecare and Hospice Topic Collection contains information for primarily non-residential services. Long-term care facilities pose unique challenges during disasters due to the vulnerability and fragility of their residents. Recent disasters have illustrated the risks to long-term care residents during facility evacuation. The promulgation of the recent CMS Emergency Preparedness Rule was designed in part to increase the mitigation and preparedness activities of long term care facilities to reduce these risks.  

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.

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Must Reads

California Association of Health Facilities. (n.d.). CAHF Disaster Planning Guide. (Accessed 4/3/2019.)
This guide was developed to assist long-term care providers with enhancing their existing emergency operations plans and procedures. It includes self-assessment tools, checklists, templates, and other resources that can be found across multiple tabs. The information contained in this guide was developed in consideration of the core concepts and guiding principles of the National Incident Management System (NIMS). The Nursing Home Incident Command System (NHICS), a derivative of the Incident Command System, is promoted throughout this guide. (Note that the template is missing specific Centers for Medicare and Medicaid Services [CMS] Emergency Preparedness [EP] Rule requirements for the facility to identify its Order of Succession and Delegation of Authority; these should be included in any COOP Plan.)
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California Association of Health Facilities (2017). Safe Evacuation Table Top Exercise for Long Term Care Facilities.
This guidebook is designed to help long-term care facilities evaluate their preparedness for an evacuation. It contains the materials necessary to conduct a simulated evacuation using a tabletop exercise. The evacuation drill is detailed in four steps, and includes multiple templates and forms.
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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.
This resource 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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Centers for Medicare and Medicaid Services. (2013). Emergency Preparedness Checklist: Recommended Tool for Effective Health Care Facility Planning.
This document is an emergency preparedness checklist intended for all healthcare facilities. It can help these facilities, including long-term care facilities, determine their level of preparedness and action steps. (Note: this resource pre-dates the final Emergency Preparedness Rule.)
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Claver, M., Dobalian, A., Fickel, J., et al. (2013). Comprehensive Care for Vulnerable Elderly Veterans during Disasters. Archives of Gerontology and Geriatrics. 56(1): 205-13.
This study examined the experiences of Veterans Health Administration (VHA) nursing homes (VANHs) and the evacuation and sheltering of their residents during Hurricanes Katrina and Rita. Interviews were conducted with nursing home staff and representatives, which revealed that physical harm, psychological distress, cognitive decline, and increased social isolation were areas that deserved special attention for this vulnerable population.
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Dosa, D., Hyer, K., et al. (2012). To Evacuate or Shelter In Place: Implications of Universal Hurricane Evacuation Policies on Nursing Home Residents. Journal of the American Medical Directors Association. 13(2): 190 e1-7.
The objective of this study was to examine the differential morbidity/mortality associated with evacuation versus sheltering in place for nursing home residents exposed to four hurricanes in the Gulf region. The authors discuss their methodology and results of the study.
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Laditka, S.B., Laditka, J.N., Xirasagar, S., et al. (2008). Providing Shelter to Nursing Home Evacuees in Disasters: Lessons from Hurricane Katrina. American Journal of Public Health. 98(7): 1288-93.
The authors examined nursing home preparedness needs by studying the experiences of nursing homes that sheltered evacuees from Hurricane Katrina. Interviews were conducted with nursing home administrators that sheltered evacuees in four states. Specific supply, medication, medical records, staffing, and mental health issues were identified for targeted attention during planning.
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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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Virginia Department of Public Health. (2013). Don't Sweat It: Preparing for Disasters in Nursing Homes and Assisted Living Facilities.
This video was developed to be an educational tool for staff training on emergency preparedness specific to long-term care facilities. The scenario follows staff as they deal with a major storm that causes a week-long power outage. The video covers topics including preparedness, sheltering in place, and evacuation.
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Education and Training

Arkansas Healthcare Association and Arkansas Assisted Living Association. (2017). Emergency Preparedness Challenges Facing Long Term Care.
This presentation discusses key emergency preparedness and response-related issues facing long-term care facilities, and some best practices for addressing challenges, including those pertaining to security.
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Howard, D.H., Blake, S.C. (2012). Improving Disaster Planning in Nursing Homes and Home Health Agencies. Centers for Disease Control and Prevention.
These slides are from a webinar that discussed the results of a study conducted by the Emory University Preparedness and Emergency Response Research Center (PERRC). The study examined disaster preparedness in nursing homes and home health agencies, which have typically not been included in disaster planning efforts.
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Paarlberg, K. (2017). Emergency Planning for Institutional Facilities. ADA (Americans with Disabilities Act) National Network.
This webinar discusses evacuation considerations for assisted living facilities, nursing homes, hospitals, and jails given the challenges of mobility and/or security related to the residents of these facilities. Criteria for additional protection of residents through building construction, as well as options for planning, training of staff, practice drills, and notification, are also discussed.
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Virginia Department of Public Health. (2013). Don't Sweat It: Preparing for Disasters in Nursing Homes and Assisted Living Facilities.
This video was developed to be an educational tool for staff training on emergency preparedness specific to long-term care facilities. The scenario follows staff as they deal with a major storm that causes a week-long power outage. The video covers topics including preparedness, sheltering in place, and evacuation.
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Guidance and Guidelines

* Administration for Community Living. (2015). Emergency Preparedness and Response: Model Policies and Procedures for State Long-Term Care Ombudsman Programs. U.S. Department of Health and Human Services.
This document can help state Long-Term Care Ombudsman programs develop policies and procedures regarding emergency preparedness. While Long-Term Care Ombudsman programs are not first responders, they can play an important role in emergency planning and response. These programs can resolve complaints, protect rights, and promote access to services for residents before, during, and after emergencies and disasters.
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American Health Care Association (2014). Emergency Preparedness Requires a Communications Plan.
This document provides guidance to long-term care facilities on developing or modifying emergency preparedness communications procedures.
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Brown, L.M., and Hyer, K. (2008). Psychological First Aid: Field Operations Guide for Nursing Homes. American Health Care Association.
This guidance document provides supportive interventions designed to reduce the initial distress caused by traumatic events and help in the immediate aftermath of a disaster. It addresses the specific emotional needs and concerns of nursing home patients. The guide is intended for nurses, certified nurses' aides, social workers, and other direct-care staff.
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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.
This resource 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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* Centers for Disease Control and Prevention (2011). Interim Guidance for Influenza Outbreak Management in Long-Term Care Facilities. (Accessed 5/7/2015.)
The Centers for Disease Control and Prevention developed this resource to provide guidance for influenza outbreak management in long-term care facilities. It addresses preventing transmission of influenza viruses and other infectious agents within long-term care facilities, with a multi-faceted approach that includes vaccination, testing, infection control, antiviral treatment, and antiviral chemoprophylaxis.
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Centers for Disease Control and Prevention. (2016). Long-Term, Home Health, and Hospice Care Planning Guide for Public Health Emergencies. U.S. Department of Health and Human Services.
This planning guide is geared towards long-term care, homecare, and hospice providers and is comprised of six sections: situational awareness, continuity of operations, facility or agency operations, crisis standards of care, staffing, and fatality management.
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Connerton, P. (2013). Ethical Guidelines for the Development of Emergency Plans. American Health Care Association.
This guidance can help disaster planners incorporate ethical considerations into their documents, exercises, and other preparedness activities. The author provides a concise summary of disaster ethics principles and linkages to long-term care.
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Florida Health Care Association. (2008). Emergency Preparedness Training and Exercise Guide for Nursing Homes.
This document was created to assist nursing homes with the ongoing process of training, exercising, and evaluation to support staff preparedness for emergency response.
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Florida Healthcare Association. (2012). Defining Emergency Operations Basic Plan Elements: Modified for Nursing Homes from FEMA (Federal Emergency Management Agency)'s Comprehensive Preparedness Guide (CPG) 101.
This document was developed to assist executive and administrative leadership teams at skilled nursing facilities and nursing homes to develop their emergency operations plans
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* Administration for Community Living. (2015). Emergency Preparedness and Response: Model Policies and Procedures for State Long-Term Care Ombudsman Programs. U.S. Department of Health and Human Services.
This document can help state Long-Term Care Ombudsman programs develop policies and procedures regarding emergency preparedness. While Long-Term Care Ombudsman programs are not first responders, they can play an important role in emergency planning and response. These programs can resolve complaints, protect rights, and promote access to services for residents before, during, and after emergencies and disasters.
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The Office of the Assistance Secretary for Planning and Education (ASPE). (2015). Compendium of Residential Care and Assisted Living Regulations and Policy: 2015 Edition. U.S. Department of Health and Human Services.
This compendium (produced before the CMS Emergency Preparedness Rule was enacted) provides an overview of residential care and assisted living regulations, explains the various funding streams, and provides a snapshot of state profiles that were current in 2015.
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Lessons Learned

Blanchard, G., and Dosa, D. (2009). A Comparison of the Nursing Home Evacuation Experience between Hurricanes Katrina (2005) and Gustav (2008). Journal of American Medical Directors Association. 10(9): 639-43.
The authors of this report discuss their findings from a study in which they conducted telephone surveys with multiple nursing home administrative directors in Louisiana after Hurricanes Katrina and Gustav. The objective was to ascertain whether nursing home facilities were more prepared to evacuate their nursing home facilities for Hurricane Gustav then they were for Hurricane Katrina.
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Brown, L. M., Hyer, K., Schinka, J., et al. (2010). Use of Mental Health Services by Nursing Home Residents After Hurricanes. Psychiatric Services. 61(1): 74-7.
The authors of this report discuss the findings of their study on the evaluation of pre- and post-hurricane mental health service use in Florida nursing homes. Results indicated that although most nursing homes provided some type of mental health service during normal operations, disaster-related mental health services were not routinely provided to residents. The authors also found that receiving facilities were more likely than evacuating facilities to provide treatment to evacuated residents.
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Centers for Medicare & Medicaid Services. (2023). COVID-19 Nursing Home Data. U.S. Department of Health and Human Services.
This resource page displays data reporting by certified Medicare skilled nursing facilities and Medicaid nursing facilities. Users may view individual facility data as well as view maps of total resident cases and deaths by state and resident cases and deaths per 1,000 residents by state.
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Centers for Medicare and Medicaid Services. (2017). Tribal Nursing Home Best Practices: Emergency Preparedness.
This document highlights five nursing homes in Indian Country and provides information on their emergency preparedness plans, partners, training, and funding sources. It also includes recommendations from these facilities on what has worked well for them as it relates to emergency preparedness.
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Christensen, J.J., Brown, L.M., and Hyer, K. (2012). A Haven of Last Resort: The Consequences of Evacuating Florida Nursing Home Residents to Nonclinical Buildings. Geriatric Nursing. 33(5): 375-83.
The authors of this study conducted a series of six focus groups with nursing home administrators and directors of nursing who worked in nursing homes during the 2004-2005 Florida hurricane season. The purpose of the focus groups was to explore issues faced by nursing home administrators, nurses, and residents during hurricane evacuations to nonclinical buildings.
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Claver, M., Dobalian, A., Fickel, J., et al. (2013). Comprehensive Care for Vulnerable Elderly Veterans during Disasters. Archives of Gerontology and Geriatrics. 56(1): 205-13.
This study examined the experiences of Veterans Health Administration (VHA) nursing homes (VANHs) and the evacuation and sheltering of their residents during Hurricanes Katrina and Rita. Interviews were conducted with nursing home staff and representatives, which revealed that physical harm, psychological distress, cognitive decline, and increased social isolation were areas that deserved special attention for this vulnerable population.
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Dolan, J. (2011). The Joplin Tornado: A Long Term Care Perspective. Missouri Health Care Association.
These slides were presented at the 2011 Public Health & Medical Disaster Response in Action: The Joplin Story conference, held November 15-16, 2011 in Omaha, NE. The presentation discusses the impact of the May 22, 2011 tornado on long-term care facilities in Joplin, MO and offers recommendations for disaster preparedness in these facilities going forward.
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Dosa, D., Hyer, K., et al. (2012). To Evacuate or Shelter In Place: Implications of Universal Hurricane Evacuation Policies on Nursing Home Residents. Journal of the American Medical Directors Association. 13(2): 190 e1-7.
The objective of this study was to examine the differential morbidity/mortality associated with evacuation versus sheltering in place for nursing home residents exposed to four hurricanes in the Gulf region. The authors discuss their methodology and results of the study.
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Florida Health Care Association (2007). Caring for Vulnerable Elders during a Disaster: National Findings of the 2007 Nursing Home Hurricane Summit.
The second Southeastern Nursing Home Hurricane Summit was held in St. Petersburg Beach, Florida on May 21-22, 2007. This summary document includes lessons learned, promising practices, experiences, research findings, and guidance on disaster preparedness for elders.
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Goldstraw, P., Strivens, E., Kennett, C., et al. (2012). The Care of Older People during and after Disasters: A Review of The Recent Experiences in Queensland, Australia and Christchurch, New Zealand. Australasian Journal on Ageing. 31(2): 69-71.
The authors of this article discuss the impacts that the cyclone and earthquake that struck Queensland, Australia and Christchurch, New Zealand, respectively, had on the elderly population. They note the importance of geriatrician’s involvement in disaster management. Lessons learned from these disasters and suggestions for mitigation are also provided in this article.
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Laditka, S.B., Laditka, J.N., Xirasagar, S., et al. (2008). Providing Shelter to Nursing Home Evacuees in Disasters: Lessons from Hurricane Katrina. American Journal of Public Health. 98(7): 1288-93.
The authors examined nursing home preparedness needs by studying the experiences of nursing homes that sheltered evacuees from Hurricane Katrina. Interviews were conducted with nursing home administrators that sheltered evacuees in four states. Specific supply, medication, medical records, staffing, and mental health issues were identified for targeted attention during planning.
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Levinson, D.R. (2012). Gaps Continue to Exist in Nursing Home Emergency Preparedness and Response During Disasters: 2007-2010. U.S. Department of Health and Human Services Office of Inspector General.
In a 2006 report, results indicated that nursing homes that experienced hurricanes lacked many provisions recommended by experts in their emergency plans. In response, the Centers for Medicare & Medicaid Services (CMS) issued guidance checklists for emergency planning of healthcare facilities, long-term care ombudsman programs, and state survey agencies. This study was conducted to assess emergency preparedness and response of nursing homes that experienced disasters from 2007-2010.
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McGrady, E., Blanke, S.J., and Swanson, C. (2014). Hospice Patient Evacuation: A Case for Using a Checklist for Safe Disaster Response. (Free registration required.) American Journal of Hospice and Palliative Care. 31(3): 260-8.
This study was conducted to provide lessons learned from the experience of a small, rural hospice care organization to an actual crisis that required evacuation of the facility. A process improvement framework using the emergency response certification guidelines was used to provide details of the incident, analyze the effectiveness of disaster planning and response in response to an actual crisis, and discuss the post-event review, lessons learned, and process improvement.
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Nomura, S., Blangiardo, M., Tsubokura, M., et al. (2016). Post-Nuclear Disaster Evacuation and Survival Amongst Elderly People in Fukushima: A Comparative Analysis Between Evacuees and Non-Evacuees. Preventative Medicine. 82: 77-82.
Elderly residents of care facilities evacuated after a disaster experienced a three-fold increase in mortality compared to baseline mortality in a control group. This potential impact should be considered in evacuation decision-making.
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Seale, G. S. (2010). Emergency Preparedness as a Continuous Improvement Cycle: Perspectives from a Postacute Rehabilitation Facility. (Abstract only.) Rehabilitation Psychology. 55(3): 247-54.
The objectives of this study were to describe the iterative process of emergency planning and preparedness as it relates to post-acute rehabilitation facilities. The study focused on facility staff involved in the evacuation and ongoing care post evacuation, and adults with moderate to severe acquired brain injury receiving residential post-acute rehabilitation and long-term care services.
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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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Willoughby, M., Kipsaina, C., Ferrah, N., et a.. (2017). Mortality in Nursing Homes Following Emergency Evacuation: A Systematic Review. (Abstract only.) Journal of the American Medical Directors Association. 18(8): 664-670.
The authors examined 15 years’ worth of peer-reviewed studies to understand the risk related to mortality among nursing home residents within 6 months after a disaster-related evacuation. More vulnerable patients were over 80 years old, frail, dependent, and male with multiple comorbidities.
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Plans, Tools, and Templates: Emergency Planning

Alabama Nursing Home Association. (2019). Long Term Care Preparedness Toolkit Base Plan.
This toolkit was developed to assist with emergency preparedness planning for long-term care facilities and can be used by facility owners, administrators, and staff. It includes sample templates, forms, and other resources. (Note: Appendix L contains an “Exercise, Evaluation, and Improvement Planning Checklist and AAR/IP.)
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California Association of Health Facilities. (n.d.). CAHF Disaster Planning Guide. (Accessed 4/3/2019.)
This guide was developed to assist long-term care providers with enhancing their existing emergency operations plans and procedures. It includes self-assessment tools, checklists, templates, and other resources that can be found across multiple tabs. The information contained in this guide was developed in consideration of the core concepts and guiding principles of the National Incident Management System (NIMS). The Nursing Home Incident Command System (NHICS), a derivative of the Incident Command System, is promoted throughout this guide. (Note that the template is missing specific Centers for Medicare and Medicaid Services [CMS] Emergency Preparedness [EP] Rule requirements for the facility to identify its Order of Succession and Delegation of Authority; these should be included in any COOP Plan.)
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California Association of Health Facilities. (n.d.). Emergency Operations Plans. (Accessed 7/10/2019.)
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 Association of Health Facilities Disaster Preparedness Program. (n.d.). Continuity of Operations Plan Template for Long Term Care Facilities. (Accessed 5/22/2019.)
This is a continuity of operations plan template for long-term care facilities that may be customized as needed.
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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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Centers for Medicare and Medicaid Services (2007). Emergency Planning Checklist: Recommended Tool for Persons in Long-Term Care Facilities and Their Family Members, Friends, Personal Caregivers, Guardians and Long-Term Care Ombudsmen.
This emergency preparedness checklist is geared towards residents, families, and other interested parties. It includes sections for long-term care ombudsmen, and long-term care residents, their family members, friends, personal caregivers, and guardians. Topics include emergency planning and relocation.
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Florida Healthcare Association. (2008). Emergency Management Guide for Nursing Homes. (Appendix Q, p. 112 of Emergency Management Guide for Nursing Homes.)
Though not updated since the 2016 Centers for Medicare and Medicaid Services (CMS) Emergency Preparedness (EP) Rule was issued, this planning guide provides useful guidance for developing an emergency management plan for a long-term care facility. It is comprised of six sections, 28 appendices, a multitude of job action sheets, and nine sample statements that other states can used when creating or updating their plans. Each of the sections references specific nursing home issues and easily replicable. It also includes a sample letter that nursing home administrators may use to communicate with families about facility preparedness efforts and emergency response. The plan also provides an established format for developing a basic plan; offers direction for developing standard operating procedures for use during an emergency; and addresses specific hazards which may threaten a facility.
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Florida Healthcare Association. (2016). Post-Storm Recovery Planning Considerations.
This document provides post-storm recovery guidance and checklists for nursing homes/ long term care facilities.
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Minnesota Department of Health. (2017). 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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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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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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Washington State (n.d.). Disaster Preparedness Plan: Template for use in Long Term Care Facilities. (Accessed 3/8/2019.)
This is a template plan intended to be used and completed by long-term care facilities. It provides situations, assumptions, legal authorities, concept of operations, a list of roles and responsibilities, and checklists for various hazards.
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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: Evacuation and Shelter-in-Place

American Healthcare Association. (2015). Shelter In Place: Planning Resource Guide for Nursing Homes.
This guide discusses the steps needed to prepare to shelter-in-place, and the related considerations and potential exposures nursing homes must account for in developing applicable decision criteria and protocols. Detailed planning worksheets and decision trees are included. (Note that this guide was created prior to the release of the 2016 Centers for Medicare and Medicaid Services [CMS] Emergency Preparedness [EP] Rule, which planners should reference to ensure compliance for their organizations.)
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Arkansas Health Care Association. (2017). Evacuation Drill for Long-Term Care Facilities.
This document provides guidance to long-term care facilities that are evaluating their preparedness levels for an evacuation. It contains the materials needed to conduct a simulated evacuation using a tabletop exercise.
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Blake, S.C., Howard, D.H., Eiring, H., and Tarde, S. (2012). San Diego's Area Coordinator System: A Disaster Preparedness Model for US Nursing Homes. (Abstract only.) Disaster Medicine and Public Health Preparedness. 6(4): 424-7.
In October 2007, a series of wildfires burned over 500,000 acres in Southern California causing 14 nursing homes to evacuate more than 1,200 residents. In response to this event, nursing home administrators and officials from various healthcare and emergency management agencies in San Diego County collaborated to form a model for nursing home emergency preparedness. The authors of this report describe the model, known as the area coordinator system, and discuss its strengths, limitations, and how it could be replicated in other areas of the country.
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California Association of Health Facilities (n.d.). Long-Term Care Facility Evacuation: Planning Considerations. (Accessed 6/5/2019.)
This resource provides suggested emergency operations plan components for the evacuation of long-term care facilities. Provided in tabular form, it lists evacuation categories in one column and suggested responses and best practices in another. It includes general and evacuation provisions, and physical plant, re-entry, and other considerations for widespread evacuation.
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California Association of Health Facilities (2012). Long-Term Care Facility Evacuation Resident Assessment Form for Transport and Destination.
This document is an assessment form for residents of long-term care facilities who need to be evacuated and transported in an emergency. It provides information about three levels of care, facility type, transport type, and number of residents.
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* California Association of Health Facilities (2017). Safe Evacuation Table Top Exercise for Long Term Care Facilities.
This guidebook is designed to help long-term care facilities evaluate their preparedness for an evacuation. It contains the materials necessary to conduct a simulated evacuation using a tabletop exercise. The evacuation drill is detailed in four steps, and includes multiple templates and forms.
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Florida Health Care Association. (2008). National Criteria for Evacuation Decision-Making in Nursing Homes. Florida Health Care Education and Development Foundation.
This resource provides criteria for evacuation decision-making in nursing homes and is intended to assist administrators and healthcare professionals determine whether to evacuate or shelter-in-place during disasters. It also includes guidance on the evacuation process.
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Greater New York Hospital Association. (2017). Patient Evacuation Toolkit.
This toolkit contains resources developed by the "Patient Movement Workgroup" and addresses four priority areas: defining bed types to make bed matching easier; sharing critical information during transport; improving access to medical records after patient transfer; and best practices for credentialing healthcare personnel. It also includes information on Transportation Assistance Levels (stretcher, wheelchair, and ambulatory) and a downloadable job aid worksheet (p. 10).
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Michigan Region 6. (2010). Evacuation Drill for Long Term Care Facilities.
This guidebook is designed to help long-term care facilities evaluate their preparedness for an evacuation. It contains the materials necessary to conduct a simulated evacuation using a tabletop exercise.
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New York State Department of Health. (2011). Nursing Home Evacuation Plan.
This workbook provides considerations for nursing home facilities that are developing or updating their evacuation plans. It is intended to be used in any emergency requiring either a full or partial evacuation of the nursing home.
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Plans, Tools, and Templates: Exercises

* California Association of Health Facilities (2017). Safe Evacuation Table Top Exercise for Long Term Care Facilities.
This guidebook is designed to help long-term care facilities evaluate their preparedness for an evacuation. It contains the materials necessary to conduct a simulated evacuation using a tabletop exercise. The evacuation drill is detailed in four steps, and includes multiple templates and forms.
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District 1 [Michigan] Regional Medical Response Coalition. (2010). Situation Manual: Shelter-In-Place/Evacuation Tabletop Exercise: Long Term Care Facility.
This Situation Manual includes exercise materials from Michigan, where exercise participants were given the tools to implement and evaluate the Long Term Care Facility (LTC) tabletop exercise. The purpose of this exercise was to provide a forum for LTCs and other organization to participate in a facilitated discussion regarding their roles and responsibilities during shelter-in-place and evacuation emergencies.
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Health Care Association of New Jersey. (2012). Mid Summer’s NightMARES: Situation Manual.
This Situation Manual provided exercise participants in New Jersey with the tools to implement and evaluate the tabletop exercise related to long-term care facilities. The purpose of this exercise was to provide participants with an opportunity to evaluate their long-term care facility’s current medical surge capabilities in response to a severe weather event. It focused on the implementation and coordination of internal emergency management plans, policies and procedures, critical decision making, communications capabilities and the ability to manage a disaster situation requiring medical surge or evacuation of residents into the facility’s operations.
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Health Care Association of New Jersey. (2012). Project ESCAPE (Evaluate Surge Capacity and Prioritized Evacuation) Full Scale Exercise: After Action Report/Improvement Plan.
This after-action report provides a summary of the Central West Medical Coordination Center regional mass casualty exercise. Organizers developed two objectives for this exercise: evaluate the ability to evacuate residents from a long-term care facility and evaluate medical surge into an acute care hospital. This document can also serve as a template for other community exercises.
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Plans, Tools, and Templates: Pandemic/Epidemic Influenza Planning

American Health Care Association and National Center for Assisted Living. (2013). Caring for Persons with Dementia during an Influenza Pandemic. American Health Care Association.
This basic guide is for non-clinical staff who become involved in direct patient care during an influenza pandemic or other emergency particularly if they do not normally care for patients with dementia. The document addresses areas of concern for long-term care residents with dementia that may require special attention during an influenza pandemic, along with potential response strategies.
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Amirov, C., Howard, P., and Kohm, C. (2007). Influenza Pandemic Planning: One Organization’s Experience. (Abstract only.) Healthcare Management Forum. 20(1): 16-9.
The authors of this article describe the influenza pandemic planning process that was conducted by a geriatric facility in Toronto, Canada. The facility developed a pandemic plan in order to ensure preparedness for staff, clients, and families.
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Anderson, E. and Montgomery, J. (2010). Pandemic Influenza Workbook for Long Term Care Providers. California Association of Health Facilities.
This state-specific report provides guidance to long-term providers on what actions to take to protect the health and safety of the staff and residents in their facilities in the event of a pandemic influenza outbreak (e.g., vaccines/antivirals, PPE use, staff impact and augmented supply management). It may be used to develop a hazard-specific Pandemic Influenza Plan Annex to a facility’s Emergency Operations Plan.
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* Centers for Disease Control and Prevention (2011). Interim Guidance for Influenza Outbreak Management in Long-Term Care Facilities. (Accessed 5/7/2015.)
The Centers for Disease Control and Prevention developed this resource to provide guidance for influenza outbreak management in long-term care facilities. It addresses preventing transmission of influenza viruses and other infectious agents within long-term care facilities, with a multi-faceted approach that includes vaccination, testing, infection control, antiviral treatment, and antiviral chemoprophylaxis.
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Centers for Disease Control and Prevention. (2020). Post-acute and Long-term Care Facility Toolkit: Influenza Vaccination among Health Care Personnel. U.S. Department of Health and Human Services.
This toolkit has sub links in three areas: staff vaccinations; increasing coverage and other vaccine-related information. It is intended to inform long-term care facilities and their owners about the importance of influenza vaccination among their workforce.
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Minnesota Department of Health. (2023). Long-Term Care (LTC) Emergency Preparedness. (Added 9/4/2020.)
This resource page for LTC owners, administrators, and staff and their emergency preparedness partners includes downloadable Word templates to create contingency staffing and testing plans for LTCs. Also included are webinar recordings describing how to use each of the plan templates and guidance on effectively developing a testing plan using the template. While developed for the COVID-19 pandemic, these resources may be used for other epidemics that stress staffing and testing resources.
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Mody, L., Langa, K.M., and Malani, P. (2006). Impact of the 2004-2005 Influenza Vaccine Shortage on Immunization Practices in Long-Term Care Facilities. Infection Control and Hospital Epidemiology. 27(4): 383-7.
The objective of this study was to assess the response of long-term care facilities to the 2004-2005 influenza vaccine shortage and the impact on resident and healthcare worker (HCW) immunization rates. The authors found a five percent decrease in HCW vaccination and only 17 out of 216 facilities reported “intensified infection control measures in response to the vaccine shortage.” Information on non-pharmaceutical interventions implemented to offset decreased vaccination coverage among staff and patients may be helpful to planners in preparing for future vaccine shortages.
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New Jersey Hospital Association (2010). Planning Today for a Pandemic Tomorrow: A Tool for Nursing Facilities.
This tool is intended to assist nursing facilities in developing their pandemic preparedness and response plans. It consists of several modules, which are to be used as a guide to facilitate discussion and to ensure that key points related to a specific topic, such as human resources, are identified and addressed in the planning process. It also includes sample policies and procedures and a module on ethics/values.
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Nuno, M., Reichert, T.A., Chowell, B., and Gumel, A.B. (2008). Protecting Residential Care Facilities from Pandemic Influenza. Proceedings of the National Academies of Science of the United States of America. 105(30): 10625-30.
The authors of this study modeled a residential care facility to determine if conditions exist under which non-pharmaceutical interventions (NPIs) alone might prevent the introduction of a pandemic virus. They found that “the effectiveness of NPIs depends strongly on a timely implementation and full compliance,” and that “great risks are associated with premature relaxation of these control measures.”
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U.S. Department of Health and Human Services, and Centers for Disease Control and Prevention (n.d.). Long-Term Care and Other Residential Facilities: Pandemic Influenza Planning Checklist.
The Centers for Disease Control and Prevention developed this checklist to help long-term care and other residential facilities assess and improve their preparedness for responding to pandemic influenza. It identifies key areas for pandemic influenza planning. Long-term care and other residential facilities can use this checklist to self-assess the strengths and weaknesses of current planning efforts. This tool also provides links to websites with helpful information.
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Studies

Castle, N.G. (2008). Nursing Home Evacuation Plans. American Journal of Public Health. 98(7): 1235-40.
The author of this study examined evacuation plans from 2,134 nursing homes and analyzed national data to determine the types of deficiencies cited in their evacuation plans. Data was collected from 1997 to 2005, and the following four citations were specifically examined: written emergency plans, staff training, written evacuation plans, and fire drills.
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Feret, B., and Bratberg, J. (2008). Pharmacist-based Intervention to Prepare Residents of Assisted-Living Facilities for Emergencies. (Abstract only.) Journal of American Pharmacists Association. 48(6): 780-3.
The objective of this study was to assess views of disaster preparation and readiness of assisted-living residents after a comprehensive program developed and presented by pharmacists on the importance of preparing for an emergency, specifically regarding organizing of medical information.
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Lane, S. and McGrady, E. (2016). Nursing Home Self-assessment of Implementation of Emergency Preparedness Standards. (Free registration required.) Prehospital and Disaster Medicine. 31(4):422-431.
The authors asked nursing homes in North Carolina and South Carolina to measure their preparedness using the Centers for Medicare and Medicaid Services (CMS) emergency preparedness checklist. They found that progress had been made since the 2012 Inspector General report that looked at nursing home preparedness, but gaps still persisted, especially in evacuation standards; interfacing with emergency management officials; establishing back-up evacuation sites and evacuation routes; identification of resident care items; and obtaining copies of state and local emergency planning regulations.
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Pierce, J.R., Morley, S.K., West, T.A., et al. (2017). Improving Long-Term Care Facility Disaster Preparedness and Response: A Literature Review. (Abstract only.) Disaster Medicine and Public Health Preparedness. 11(1):140-149.
The authors conducted a literature review of studied interventions or facility attributes that affect disaster outcomes in long-term care facilities (LTCF) and their residents from 1974 through September 30, 2015. They note that the following may improve outcomes: integrated and coordinated disaster planning; staff training; careful consideration before governments order mandatory evacuations; anticipation of the increased medical needs of LTCF residents following a disaster; and the need for more outcomes research.
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Agencies and Organizations

American Health Care Association/National Center for Assisted Living Emergency Preparedness.
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California Association of Health Facilities CAHF Disaster Preparedness Program.
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Centers for Disease Control and Prevention Planning Resources by Setting: Long-term, Acute, and Chronic Care.
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Florida Healthcare Association, Florida Department of Health, and Emory University. Florida Long Term Care Emergency Preparedness Portal.
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Michigan Department of Health and Human Services Long Term Care Disaster Planning Resources.
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The National Long-Term Care Ombudsman Resource Center Emergency Preparedness.
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Wisconsin Department of Health Services Emergency Preparedness for Long Term Care and Assisted Living Facilities.
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This ASPR TRACIE Topic Collection was refreshed and comprehensively updated in January and June 2019 by the following subject matter experts (listed in alphabetical order): John Hick, MD, HHS ASPR and Hennepin County Medical Cente; James L. Paturas, Director, Center for Emergency Preparedness and Disaster Response, Yale New Haven Health; Shelly Raffle, MPA, CEM, BCMS Lead Implementer, Raffle Solutions; and Michelle Veach, Life Safety Engineer, Division of Nursing Homes (DNH), Centers for Medicare & Medicaid Services.

It was comprehensively reviewed in May 2015 by the following subject matter experts (listed in alphabetical order): Peggy Connorton, MS, LNFA, Director, Quality and LTC Trend Tracker, American Health Care Association; Kristen Finne, Senior Policy Analyst, HHS/ASPR/OPP/Division of Health System Policy (DHSP); John Hick, MD, HHS ASPR and Hennepin County Medical Center; and Jocelyn Montgomery, RN, PHN, Director of Clinical Affairs, California Association of Health Facilities.

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