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A hurricane is churning up the coast. An earthquake rattles the city. A blizzard is expected to drop 30 inches of snow on the region. A gunman has been reported loose in the neighborhood. Wildfires are burning outside of town. Tornado sirens blare across the county. A small grease fire breaks out in the kitchen.

These are just some of the many emergency scenarios that confront leaders of skilled nursing and assisted living communities, as well as other centers of care for vulnerable populations. Of course, facility directors have always focused on the safety and welfare of their residents.

But new federal rules, along with a spate of tragic headlines following last and this year’s deadly hurricane and wildfire seasons, have stoked a new sense of urgency in emergency preparedness efforts across the country.

While significant challenges remain, experts say many providers are making large strides in incorporating disaster preparedness concepts and ideas into their day-to-day duties.

“We still have work to do, especially on the assisted living side,” says Jason Belden, disaster preparedness program manager for the California Association of Health Facilities (CAHF). “But we feel like we are significantly more prepared to deal with all of the challenges that come with natural or manmade disasters.”

A key force driving recent progress was last fall’s implementation of a final rule issued by the Centers for Medicare & Medicaid Services (CMS)​.

The rule, which required compliance starting Nov. 15, 2017, establishes national emergency preparedness requirements to ensure that natural and manmade disasters can be adequately planned for and coordinated with a variety of emergency preparedness systems, including federal, state, tribal, regional, and local systems.

The rule applies to the 17 provider and supplier types that accept Medicare and Medicaid reimbursement, such as long term care and skilled nursing facilities, but not assisted living communities. It addresses four core areas: 1.) risk assessment and emergency planning; 2.) policies and procedures; 3.) communications planning; and 4.) training and testing (see sidebar, below).

First and foremost, providers must conduct an “all-hazards” vulnerability assessment, says Scott Aronson, a principal with Russell Phillips & Associates (RPA), a leading emergency management consultancy for health care providers.

The aim is to identify all threats common to the provider’s location, such as tornados, earthquakes, wildfires, and hurricanes, as well as general facility-based emergencies, such as equipment and power failures, interruptions in communications, and loss of a portion or all of a facility.

Based on this analysis, providers must then develop an emergency preparedness plan that addresses each risk with strategies and processes to continue operations and services during an emergency. The resulting policies and procedures must ensure the welfare of staff and residents, including the provision of food, water, medical supplies, and pharmaceuticals, as well as alternative energy sources to maintain temperature control, emergency lighting, and sewage and waste disposal.

“We have so many types of disasters,” Aronson says. “Every one of those has a different effect on planning.”

Planning for the sheer scope of emergencies, in fact, is a challenge for many facilities. While providers in states prone to specific natural disasters often do a good job of preparing for big emergencies, they may struggle with the isolated incidents, which are actually more prevalent, Aronson says.

“They’ll know that tornadoes are a big issue in their area, so they’ll work on fine-tuning their tornado plan,” he says of procedures to move residents away from windows and into interior corridors, for example.

“But they may not handle something else as well, because they don’t have a specific threat to plan around. They haven’t beefed up any of the other areas,” he says. “At a minimum, they need to have a written plan in place.”

Covenant Retirement Communities, which operates facilities in nine states across the country, had different emergency plans for each campus. The biggest change brought by the CMS final rule was the development of one succinct emergency plan across all campuses, says Peggy Connorton, director of skilled nursing operations at the organization.

“Before the new regulation, we had 13 different plans with 13 different ways of doing things,” she says. “So if any of us had to go to a campus, we’d have to learn what was happening, look at the plan, and learn what to do quickly. With the CMS rule, it made everything more streamlined and consistent with the campuses. I think it’s made us better.”

With its new plan in place, Covenant Retirement Communities then tackled another core element of the CMS rule: training and testing.

The staff are trained upon hire and once a year after that, Connorton says. Staff members are quizzed during training as well as during random audits with questions such as, “What do you do if there was fire in this location, or what do you do if we had a tornado?” she says. “This allows us to gauge each staff member’s competency and retrain, if needed.”

Training varies somewhat depending on the location and local threats, she says. “But for the most part, the typical training would be the same for most of our campuses—power outages, fire drills, tornado watches.”

Furthermore, the entire organization gets involved. The Covenant Retirement Communities central office hosts a national “tabletop” drill with each campus via Skype. Campus leaders participate in the drill, which is based on a scenario such as a power outage or fire, and together the group identifies any areas that must be changed to the emergency plan, training, or resources. 

The importance of training can’t be overestimated, leaders say. Nowhere is this more evident than in Florida, where hurricanes are a common occurrence.

Providers there are constantly training for the next big storm, says Emmett Reed, executive director of the Florida Health Care Association (FHCA), which represents 82 percent of skilled nursing facilities in Florida, housing 68,000 residents.

In fact, when the CMS rule kicked in last year, most FHCA-member providers had to make only minor changes from what they already were doing, he says.

According to FHCA, over the past year 1,500 long term care professionals have taken part in FHCA emergency preparedness training, including community-based discussion, disaster drills, and educational seminars.

In addition, a recent survey by Emory University found that 94 percent of Florida nursing centers have regular communications with local emergency management agencies, and 88 percent discuss emergency preparedness with their residents.

Still, each hurricane offers its own unique lessons.

Last fall’s Hurricane Irma, for instance, was unlike anything Reed had ever seen. “The breadth and width of damage and scope of the storm was so catastrophic and major that it really pushed all of our emergency preparedness to the limits,” he says. “Literally, there was a time when the entire state was without power.”

The major lesson, Reed says, is that each care center has to be self-sustaining. A multisite facility, for instance, couldn’t rely on backup from other facilities to come to its aid.

“In past storms, if your generator broke down, or if you didn’t have enough fuel, you’d make a phone call to a facility 50 miles up the road, and somebody would have help on the way very quickly,” Reed says. “That wasn’t the case this year, because everybody was in crisis mode. We have to think as if the cavalry isn’t going to arrive as quickly as we’re used to if another storm like Irma comes.”

Roughly 400 facilities lost power during Hurricane Irma, yet all 68,000 residents in the facilities represented by FHCA made it safely through the storm.

The importance of training may be self-evident. But the new CMS requirement around coordinating community-based training exercises with local health and emergency management agencies has presented challenges for some providers.

Many providers have struggled to get local emergency authorities to the table, Aronson says.

“Picture you’re the emergency manager, and all of a sudden a new regulation comes out from the federal government,” he says. “You’ve got 15 nursing homes in your area, and now you’re getting 15 phone calls, which are going to take 4-5 hours to address each one, and you’re a part-timer. All of a sudden your normal job just got expanded because everyone is calling you.”

Aronson applauds providers for trying to do the right thing, even if they’re not getting the right response.

“Still, they ultimately need to document that they reached out, document the response, and keep trying.”

Some states and localities are better equipped than others to connect providers with emergency agencies.

In Florida, the Miami Jewish Health Systems works with the Miami-Dade County Emergency Operations Center on its hurricane preparedness drills, says Jason Pincus, Miami Jewish Health’s vice president of operations and nursing home administrator. “We have a very close relation with them,” he says. “It’s important as we’re preparing for these storms to get best practices from them.”

Even in communities highly attuned to emergency preparedness, communications can break down. Such was the case around the rules and priorities of order for restoring power after Hurricane Irma, says Miami Jewish Health President and Chief Executive Officer Jeffrey Freimark.

Miami Jewish Health placed many calls to Florida Power & Light requesting the restoration of power. “They were clearly scrambling,” says Freimark. “There was some confusion as to where in the priority order nursing homes were placed. There is a lot of work being addressed going forward.”

Others have witnessed an even greater breakdown in communications.

In California, communication between facilities and local emergency authorities is still poorly managed in a disaster, says CAHF’s Belden.

“Most of the providers affected by the fires, floods, and mudslides received little or no communication from the emergency response community to direct them on evacuation routes, staging areas, or shelter-in-place advice,” he says.

In such cases, Belden advises taking a proactive approach: Providers must have their own situational awareness at all times. They must participate in their local communities’ preparedness activities. And they must let responders know of any special needs that their residents have when a disaster strikes.

“If you need 25 ambulances in order to evacuate, then the responders need to know of those needs beforehand, not during the event,” Belden says. “That is why it is critical for facilities to understand how they fit in the greater emergency response structure, and to sit at a table with those folks and let them know what kind of resources they will need in a disaster so that plans can be made to accommodate their needs.”

Brookdale Senior Living, which operates more than 1,000 assisted living communities in 46 states, says communicating effectively with local authorities is a major component of its emergency preparedness plan. 

That plan at Brookdale Fountaingrove in Santa Rosa, Calif., was put to the test last October during the fast-moving Santa Rosa wildfires.

The facility received a dreaded phone call in the middle of the night to evacuate. Dramatic video captures a string of residents being rolled across a parking lot in wheelchairs and placed on a bus. The bus driver then whisks his charges to safety, but not before driving past threatening fires and blowing embers on either side of the road.

The Brookdale facility had never experienced an event of this scale, and in such a short amount of time, says Brookdale spokeswoman Heather Hunter.

When the call came, staff members followed the lead of local emergency personnel, she says.

Responders’ efforts were aided by Brookdale’s own disaster plan, which included outfitting residents with enhanced identification bracelets to determine an accurate headcount and making housing arrangements with nearby sister facilities. In addition, the facility had developed enhanced mobile disaster kits that included first-aid provisions, information on residents’ needs, flashlights, batteries, a hammer, and gloves.

“We were able to swiftly mobilize 107 residents who live in that community and move them out of harm’s way,” Hunter recalls. “With residents being displaced for more than 24 hours, we were able to use our size to our favor,” she says. “We could provide transportation and shelter to evacuated residents until they were able to return home.”

Similarly, a detailed fire evacuation plan was in place and on standby at Covenant Retirement Communities’ facility in Santa Barbara, Calif.

Pre-evacuation planning included ensuring the residents had all of their medications and other personal items handy, Connorton says. “The staff made a little backpack for every resident, so they were ready to go at a moment’s notice if they needed to.”

Covenant Retirement Communities also has an emergency backup plan for residents’ medical records. Every night, a back-up code is sent to the health care administrators so if they had to evacuate, they could put everything on a jump drive and take it with them. The use of portable laptops and storage of medical records on a web-based platform also ensures continuity of care in the face of an emergency.

While communicating with residents and local emergency officials is crucial, it’s important to remember the residents’ families. A strong communications plan to inform loved ones of developments during an emergency is another crucial element of any emergency plan.

Brookdale used social media and its online newsroom, the Brookdale Newsbeat, to post updates several times a day. “Both channels became very important in communicating with families, friends, and even the local media,” Hunter says.

Similarly, communication to the outside world was a top priority at Miami Jewish Health during Hurricane Irma. The large facility was active on social media during and after the hurricane, says Churé Gladwell, vice president and chief development officer at Miami Jewish Health.

Gladwell, who was onsite during the hurricane, sent messages to an off-site colleague who would then post on social media and the website. The colleague had her own computers at home, as well as a mobile phone and iPad with different cell phone carriers.

“So no matter what, she had three different ways to get messaging out,” Gladwell says of the system, which worked even when the power went out. “She could assure family members that their loved ones were cared for.”

Recognizing the importance of such reassurance, and preparing for even larger storms, Miami Jewish Health plans to beef up its external communications technology by purchasing additional satellite phones and radios and burying communication cable lines underground.

Preparing for any type of emergency requires an investment in time and money. CMS has estimated that implementing the emergency rule would cost roughly $373 million in the first year, as the more than 72,000 affected providers and suppliers accepting Medicare and Medicaid reimbursement conduct risk assessments and develop emergency preparedness plans. After that, annual costs to test plans and train staff will be $25 million, CMS says.

This is not an insignificant burden. CAHF’s Belden says the CMS requirements fall far outside of the scope of what most providers previously had to think of or plan for.

“The leadership of each facility is now faced with a lengthy learning process in order to meet these requirements, and an addition of hundreds of man hours to prepare for meeting these regulations,” he says.

Time and costs are clearly an issue, says FHCA’s Reed.

“Many facilities are working off of razor-thin margins, and yet are expected to become safer and safer.” In Florida, he says, FHCA is constantly working with the legislature to try to ensure adequate funding.

RPA’s Aronson agrees the new CMS rules impose a new level of burden on providers, some of which are barely breaking even, if that.

“But the fact of the matter is, it’s a best practice,” he says of the rule. “This is what you need to do. Your job in the facility is to protect the residents and their staff. I’m not a huge advocate of federal regulations. But I am an advocate here. The framework put in place is truly going to have a long-term effect on helping to protect the residents.”

One way to ease the financial and time burden—as well as significantly improve a facility’s emergency preparedness—is to join a local, state, or regional health care coalition.

Massachusetts, for example, this spring was preparing to run five disaster exercises over the months of June and July. The annual exercises cover all licensed skilled nursing facilities in the state, plus assisted living and several other groups. They are conducted in each region, with everyone exercising together, a convenience that allows all facilities to meet the new CMS training requirements.

“When a facility doesn’t participate, you scratch your head, and wonder, ‘Why wouldn’t you? You just had this opportunity,’” Aronson says.

Reed also touts the benefits of coalitions. He points to the tragedy at a Hollywood, Fla., nursing facility in which 12 residents died following Hurricane Irma. This facility wasn’t an FHCA member.

“I plead with any nonmember,” he says. “It doesn’t have to be our organization, but join some organization that has disaster preparedness, and send your people to continuing education so that they know how to handle these situations. I’m convinced that had some of these folks who had experienced these tragedies come to our continuing education courses, they could have avoided these tragedies.”