Emergency Preparedness: When Is It Enough?

By Lori Smetanka and Beverley Laubert

Recent natural disasters exposed long-term-care facilities’ and com­­munity care systems’ levels of pre­­paredness to handle emergencies and protect their residents and patients. Hurri­canes and wildfires have tested communities’ emergency readiness and ability to respond. The failure of these providers to be prepared, or to effectively implement procedures that would protect their frail, vulnerable populations, has resulted in serious health consequences, even death.
Long-term-care facilities have long been required by law to have detailed emergency response plans and procedures in place. But these regulations were not clear on what details were to be included in the plans, only requiring that facilities be prepared to meet all poten­tial emergencies and disasters; specifically fires, severe weather and residents who go missing. Facilities also were required to train employees in emergency procedures, and to carry out random drills for staff.
The Katrina Effect
There were significant plan failures from Hurricane Katrina, which resulted in 215 deaths of nurs­ing home residents and hospital patients due to flooding and botched evacua­tions, including the deaths of 35 residents from one nursing home. Considerable federal attention and resources were directed to this area.
The Centers for Medicare & Medi­­caid Services (CMS) has coordinated federal working groups around emergency preparedness and a Survey & Certification Emergency Preparedness Stake­holder Communication Forum. These actions have helped CMS gather and develop response re­sources, which include Emergency Preparedness Checklists for long-term-care providers, for people living in long-term-care facilities and their families and ombudsmen, as well as for people with medical needs living at home. CMS also es­tablished websites on emergency preparedness, which provided additional guidance for state sur­vey agencies and healthcare providers. But has this all been enough?
Despite the efforts at federal, state and local levels following Hurricane Katrina, the Office of Inspector General (OIG) found that among twenty-four nursing homes that experienced natu­ral disasters between 2007 and 2010, many problems persisted in these facilities’ nursing home emergency preparedness. The problems included lack of collaboration with local emergency man­agement, unreliable trans­portation contracts and lack of relevant information in emergency plans.
New Rules, but Concerns Remain
The OIG recommended publishing new rules with specific requirements for emergency plans and train­ing, updated guidance on compliance with emergency plans and increased use of the CMS checklists. As a result of these recommendations, CMS wrote more comprehensive rules around emergency preparedness, and issued them in 2016. And, in 2015, the Administration for Community Liv­ing came up with model policies and procedures for long-term-care ombudsman programs for emer­gency preparedness.
Today, however, concerns remain that many facilities are not ready for emergencies, and that stronger oversight and standards enforcement are needed. Following Hurricane Irma, the deaths of 14 residents in a Florida nursing home during a period of high heat and humidity highlight the dangers and seriousness of inadequate preparation. 
A recent article by Kaiser Health News reported that across the past four years, 2,300 nursing facility violations around emergency plans and readiness were cited, including failure to inspect and test generators, and all but 20 were categorized as minor deficiencies that caused no actual harm to residents. 
In 2016, CMS issued new regulations that require 17 different provider types, including nursing facilities, to maintain an emergency preparedness program that meets all federal, state and local requirements, including emergency plans that are reviewed and updated annually; development of policies and procedures based on the emergency plan; a communication plan; training and testing of the plans, policies and procedures; and emergency and standby power systems. 
Careful Planning—the Best Response
Just having the rules in place, however, only goes so far. Sufficient implementation, monitoring and enforcement also are critical. So how to minimize the effects of emergency or disaster situations? 
Plans must be developed and tested in coordination with emergency preparedness personnel. Most long-term-care facility surveyors have neither the necessary expertise to evaluate emergency plans, nor the ability to determine the facility’s readiness to implement that plan. A state-designat­ed emergency preparedness office should certify plans, and failure to comply with emergency re­quirements should result in a stringent and mandatory federal civil monetary penalty.
Preparedness includes considering all potential hazards and having generators, the requisite fuel to operate a facility’s systems and staff competency to operate backup systems. The emer­gency response will be contingent upon the disaster, so facilities must have plans for sheltering in place, or for evacuation to nearby and farther-out locations. Local and-or state emergency man­agement agencies should have copies of plans from facilities within their jurisdiction to more ef­fectively manage the response.
Residents and families need to ask about the existence of an emergency plan, know what it en­tails and be able to access it from outside the facility. Facilities must be encouraged to include residents and families in emergency plan development, re-evaluation and implementation.
The Ombudsman Role
There is a role for the long-term-care ombudsman to advocate for residents in emergency situa­tions. Regulators should determine whether the facility complied with requirements to implement its plan and categorize deficiencies at an appropriate level of severity, but the ombudsman’s focus should be on individual residents. In cases of evacuation, the facility should maintain a record of resident relocations so ombudsmen can contact and assist with resulting problems, such as locat­ing or replacing lost personal items like sensory aids and clothing—and advocate for quality care.
In Ohio, ombudsmen have been trained in the principles of trauma-informed care and can facili­tate education of facility staff to minimize the negative impacts of relocation. Emergency manage­ment agencies should be aware of the ombudsman’s role because she or he usually is familiar with the facility and its residents. 
After a 2003 flood in northeast Ohio, the ombudsman for a community nursing facility ensured that residents received FEMA reimbursement for lost clothing and belongings. The facility could not re-open, so the ombudsman visited relocated residents and made sure they had a satisfactory resolution of their living arrangements.
Catastrophic events will always occur, and natural disasters are increasing in regularity. The effects of emergency situations are difficult for everyone, but the trauma experienced by a frail el­der can be deadly. Those who develop and implement disaster emergency plans, and those who monitor and enforce compliance, must take facility preparedness seriously. Otherwise the toll can be too great.
Lori Smetanka, J.D., is executive director of the National Consumer Voice for Quality Long-Term Care. Beverley Laubert, M.A., is the Ohio State Long-Term Care Ombudsman.
Editor’s Note: This article appears in the January/February 2018 issue of Aging Today, ASA’s bi-monthly newspaper covering issues in aging research, practice and policy nationwide. ASA members receive Aging Today as a member benefit; non-members may purchase subscriptions at our online store.