Long Term Care Preparedness

Toolkit
Base Plan
To establish common terms, this toolkit uses “Long Term Care (LTC)
facility/agency” to include nursing homes, skilled nursing facilities (SNF),
assisted living facilities (ALF), assisted living (AL) licensed group homes,
intermediate care facility for individuals with intellectual disabilities (ICF/IID),
home care agencies, and hospice.
 LONG TERM CARE PREPAREDNESS TOOLKIT

In Partnership with the MDH and the following Regional Coalitions, and State Associations.

February 2023
Minnesota Department of Health
Health Care Preparedness Program
PO Box 64975
St. Paul, MN 55164-0975
651-201-5700
www.health.state.mn.us
Upon request, this material will be made available in an alternative format such as large print, Braille or audio
recording. Printed on recycled paper.

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Contents
Base Plan........................................................................................................................................... 1
All-Hazards .................................................................................................................................... 5
Hazard Vulnerability Analysis and Tool .................................................................................................. 6
Sample HVA Tool .......................................................................................................................... 6
Incident Command System .......................................................................................................... 8
Basic ICS Job Action Overview ..................................................................................................... 9
Building Specific Information............................................................................................................... 10
Decision Making ................................................................................................................................ 11
Sample Decision Making Tree .................................................................................................... 11
1135 Waivers..................................................................................................................................... 12
Ethical Guidelines............................................................................................................................... 13
See Appendix H for Facility Shelter in Place checklists and Response Items. .............................. 17
Evacuation Transportation ......................................................................................................... 18
Evacuation Destination Information.......................................................................................... 19
Evacuation Staffing ..................................................................................................................... 19
Memorandums of Understanding ............................................................................................. 19
Attachments and Documents .................................................................................................... 20
Recovery ........................................................................................................................................... 20
Staff Care........................................................................................................................................... 21
Behavioral Health .............................................................................................................................. 21
Exercise, Evaluation, and Improvement Planning ................................................................................. 22
Variability in Requirements ............................................................................................................ 23
For inpatient providers . ................................................................................................................. 23
For outpatient providers ................................................................................................................ 23
Regional Resources and Support Agencies............................................................................................ 24

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 LONG TERM CARE PREPAREDNESS TOOLKIT

Introduction
The Minnesota Long Term Care (LTC) Preparedness Toolkit is designed to assist with
emergency preparedness planning for this specialized health care population. LTC
facilities/agencies, as they are referred to in the toolkit, include nursing homes, skilled
nursing facilities (SNF), assisted living facilities (ALF), assisted living (AL) licensed group
homes, intermediate care facility for individuals with intellectual disabilities (ICF/IID), home
care agencies, and hospice.
Members of the Minnesota Department of Health, Care Providers of Minnesota,
LeadingAge of Minnesota, Minnesota Home Care Association, Minnesota Network of
Hospice & Palliative Care, and regional representation from the Health Care Preparedness
Program developed this tool to assist LTC facilities in emergency preparedness. Latest
revisions to this toolkit took place in the Fall of 2022 with additional input from individuals
representing LTC facilities/agencies. The CMS emergency preparedness interpretive
guidance was released and implemented in April 2021.

CMS Appendix Z resources:

• Appendix Z-QSO-21-15-ALL Appendix Z
(https://www.cms.gov/sites/default/files/2021-
04/som107ap_z_emergprep.pdf)
• A.1 CMS Emergency Preparedness Checklist
• A.2 ASPR TRACIE CMS Provider Type Definitions
• A.3 Table Requirements by Provider Type
• A.4 CMS Releases Updated Emergency Preparedness Guidance

CMS/MDH Appendix Z Resources:

• A.5 MDH Crosswalk
• A.6.1-supplemental doc
• A.6.2 resident plan
This toolkit can be used by LTC facility/agency owners, administrators/directors, and staff.
Information includes sample templates, forms, and suggested resources to develop and/or
enhance LTC facilities/agencies emergency preparedness plans within LTC throughout the
state of Minnesota. It should not be viewed as a static document but one that provides a
foundation for an all-Hazards approach to preparedness, planning, and response activities.
It is recommended that not one person at any facility be charged in preparing this plan.
Rather, it is suggested that an internal committee be formed from various disciplines within
the facility to work on this plan. This toolkit serves as a base template that can be
customized to the needs of each facility. The tools in this document are important to
address prior to a disaster or incident.

Plain Language

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Use of plain language decreases staff confusion and ensures transparency for residents and
visitors. The linked toolkit offers suggestions for how to utilize plain language in emergency
overhead paging.
Minnesota Hospital Association (2011). Plain Language Emergency Overhead Paging Toolkit
(https://www.mnhospitals.org/Portals/0/Documents/ptsafety/overhead-paging-toolkit-2011.pdf)

Continuity of Operations Plan (COOP)

A Continuity of Operations Plan (COOP) will document how the facility or agency will
perform essential operations during an emergency or long-term disruption, which might
last days or weeks. The plan will identify mission critical functions, departmental
communication methods, and alternate personnel, systems, and locations. Each facility or
agency needs a COOP to ensure they can respond effectively to a variety of situations.
The COOP is designed to coordinate department/work area strategies to ensure continuity
of operations. The plan takes an all-hazards approach that addresses natural, manmade,
and technological hazards. Implementation of a department/work area’s continuity plan
will be based on the needs of the incident and resources available. The COOP should
include succession planning for continuity purposes. A COOP does not replace a
facility/agency emergency operations plan.
Succession Planning: delegation of authority/order of succession during an emergency.

Overview of All-Hazards Approach to Planning

Recent events, including COVID-19, floods, tornados, winter storms, and other events have
stressed all types of LTC facilities/agencies and shown that better planning is needed.
Because different types of events present different challenges to LTC facilities/agency’s, an
all-hazards approach to planning is proven to be most effective and most beneficial. An all-
hazards response plan must be based on the hazards that are most likely to affect a
facility/agency and is important in directing how a response may unfold and what actions
would need to be taken. To identify the most likely hazards, a hazard vulnerability analysis
should be completed (see Appendix B for more information on the Hazard Vulnerability
Analysis).

All-Hazards
Hazards may be thought of as extreme events. A Hazard Vulnerability Analysis (HVA) is
often based on an “all-hazards approach.” This means a facility/agency begins with a list of
all possible disasters, regardless of their likelihood, geographic impact, or potential
outcome. The list may be the result of a committee brainstorming session, research, or
other methodology, and should be as comprehensive as possible.
It is helpful to divide the potential hazards into categories to focus discussion and planning.
Typical categories may include natural hazards, technological hazards, and human events.
These are certainly not requirements and should not be considered constraining. There is

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overlap between the categories as well. For example, a transportation accident may be a
technological hazard rather than a human event.
Once the complete hazards list is developed, look at it critically for items that might be
appropriately grouped together as one hazard category. Organize the list into categories.
Finally, prioritize hazards to guide the emergency planning process. The realistic factors of
time and money play a role in decisions of preparedness, and facilities must choose to apply
their limited resources where they will have the most impact. To aid prioritization, each
identified hazard is evaluated for its probability of occurrence, risk to the organization, and
the organization’s current level of preparedness.

Hazard Vulnerability Analysis and Tool

The hazard vulnerability analysis tool is simply that -- a tool. It is provided as a resource and
a starting point for organizations to evaluate their vulnerability to hazards. It may be
modified or changed in any way that is appropriate for individual facility use.
This document uses a quantitative method to evaluate vulnerability, which is not required
by CMS. The facility may find a qualitative method equally as effective.
Using this tool, each potential hazard is evaluated as described above and scored as
appropriate in the areas of probability, risk, and preparedness. The factors are then
multiplied to give an overall total score for each hazard. Note that a hazard with no
probability of occurrence for a given organization is scored as zero and will automatically
result in a zero for the total score.
It is recommended that each facility/agency evaluate the prioritization and determine the
minimum score in which no action is necessary. List hazards in descending order based on
the total score, this will prioritize the hazards in need of the facilities/agency’s attention
and resources for emergency planning. The focus will then be on the hazards of higher
priority. The minimum score determined that there is some probability and risk of the
event occurring, but the facility/agency has decided to exclude it from the planning
process. It must be noted that the acceptance of all risk is at the discretion of the facility/
agency.
*To obtain a regional HVA contact your Regional Healthcare Preparedness Coordinator
(RHPC) or to identify who your county emergency manger is see Appendix N *
*See Appendix B for the process to develop your own Hazard Vulnerability Analysis (HVA)
and Tool *

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Sample HVA Tool

Note: an electronic HVA can also be accessed through your regional health care coalition. Below is a screenshot of what the electronic HVA
looks like and how changes in Probability, Impact and Response change the Risk.

See Appendix B for more information on the Hazard Vulnerability Analysis and Tool

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Emergency Operations Plan

The following sections serve as specific components that will allow your facility/agency to
plan and prepare to meet the needs of both residents and staff in the event of an incident.
Each section will offer a description of the concept, and instructions. When combined,
these sections are the basis of an Emergency Operations Plan (EOP).
Once the EOP has been developed, it is also the role of the team to be sure that this plan is
shared with appropriate staff and that internal training is conducted. This training should be
incorporated into regularly scheduled trainings as staff changes do occur and keeping
current on any material requires periodic review.
For an EOP to maintain viability and usefulness, it needs to be updated on a scheduled
basis. As each facility grows and changes, the EOP also needs to be modified to reflect those
changes. After including every section below, your EOP will be well on the way to serving
each facility’s/agency’s need to care for staff and residents.

Communications
A communication plan for both internal and external communication is important to get the
correct message to the right people at the right time. A plan should set out goals,
strategies, communication activities, and timeframes to help facilitate communications.
See Appendix C for more information to help LTC facilities communicate with each other.

Incident Command System

In any emergency response, it is critical that clear lines of authority (chain of command)
exist within the facility/agency. This ensures that there is timely and efficient decision
making and communication. It is important to define a chain of command, designate a
facility/agency incident commander, and clarify their authority and decision-making ability.
This is an important aspect of the disaster plan.
Disaster planning needs to start at the top of the facility/agency. Bring the leaders of the
facility/agency into the planning process from the very beginning to identify and agree
upon the best course of action for the LTC facility/agency, its residents, and staff.
Facility/agency leaders should discuss the financial and clinical implications of the various
proposed response strategies. This may include items such as closing to new admissions or
agreeing to be a “surge” or overflow setting for the local hospital. Medical and
administrative priorities need to match, and your facility’s/agency’s leadership team needs
to be clear about its role and authority.
Incident Command Systems (ICS) can be used at facilities/agency’s both large and small — it
can even be used by just one person. If you have a small facility/agency, the same person
may fill multiple spots on the ICS organizational chart. Assure through practice and exercise
that one designated person is not disproportionately overburdened with their roles in an
emergency.

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It is recommended that, at a minimum the roles of: Incident Commander, Operations

Section Chief, Planning Section Chief, Logistics Section Chief, and Finance Section Chief (also
referred to as command staff) obtain the basics of ICS by taking ICS 100, ICS 200, and ICS
700. These courses and more can be found at: Federal Emergency Management Agency
Training Website (https://training.fema.gov/is/crslist.aspx?lang=en&page=1) .
Here is a video link to give all staff a brief overview of the ICS structure, and here is a video
link that depicts a scenario showing the importance of being prepared.

Basic ICS Job Action Overview

The organization chart describes the ICS chain of command and defines key response areas.
Specific personnel placed in the various roles are determined on the skills and position with
the facility/agency. Below are suggested positions for ICS roles.
Incident Commander: Leads the response, appoints section leaders, approves plans and key
actions (CEO, Administrator, Director, Director of Nursing (DON), Nursing Supervisor.)

Finance Section: Tracks all expenses, claims, activities, and personnel time and is the
record keeper for the incident (controller, accounts department, payroll.)
Logistics Section: Finds, distributes, and stores all necessary resources (maintenance
supervisor, purchasing, human resources director)
Operations Section: Handles key actions including first aid, search and rescue, fire
suppression, securing the site (DON, Department supervisors, nursing supervisor, direct
care staff.)
Planning Section: Gathers information, thinks ahead, makes and revises action plans and
keeps all team members informed and communicating. (Safety committee, Continuity of
operations planning team, etc.)

Depending on the size of the incident and capability of the facility/agency, one person may
occupy multiple positions within the section. You do not need to activate all positions – only
activate what you need for the incident. This is your basic Incident Command. If part of a
larger system, you will need to know where your ICS fits within that facilities/agency’s
structure.
See Appendix D for ICS operations, templates, Job Action Sheets, and the NICS Incident
Action Plan. Appendix D also has specific ICS structures for different incidents, to lend an
idea to specific duties during a response.

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Additional resources: California Disaster Preparedness Program

(https://www.cahfdisasterprep.com/nhics)

Facility/Agency Information and Contact Information

For an EOP to be functional, it is dependent on current and accurate information. Key to
any response is the ability to know who to notify and how to get in touch with these
personnel. For this reason, having current and accurate facility/agency information and
staff information is essential. An effective response cannot occur without personnel. The
following information needs to be maintained and updated periodically so timely
communications and response can occur. The following information is broken out into
three separate areas:
• Organizational Information: contains the contact information for facility/
agency ownership and leadership
• Emergency Contact Roster-Internal: contains the contact information for
supervisors/leaders within the facility/agency
• External Contact Information: contains emergency contacts, contractors, and
outside support services
See Appendix C for Contact lists

Building Specific Information

This information is made up of the location and characteristics of the facility/agency and
the people associated with it. As with any response, it is important to understand the
physical features of a facility/agency to maintain safety and efficiency. It is also important
to understand the occupancy and certain specific information regarding the occupants. The
facility/agency-specific information provides descriptions of the facility/agency and some
baseline information regarding staff and residents. The information contained should be
reviewed and updated annually.
See Appendix E/C for Facility/Agency Specific Information

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Decision Making
During an unplanned event knowing what needs to be done to ensure the safety of the residents as
well as the staff can be extremely stressful. The facility/agency should have a clearly delineated
decision-making tree.

Sample Decision Making Tree

Source: Emergency Sheltering, Relocation, and Evacuation for Health Care Facilities.
(https://www.health.state.mn.us/communities/ep/surge/sheltering/index.html)

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HIPAA/1135Waivers in Emergent Situations

During emergent situations, the decision to share private resident health care information
is difficult. To ensure that there is continuity of care there may be situations where it is
necessary to waive HIPAA.
See Appendix G for HIPAA Wavier Toolkit

Source: hhs.gov
(https://www.hhs.gov/sites/default/files/ocr/privacy/hipaa/understanding/special/emerge
ncy/emergencyprepdisclose.pdf)

1135 Waivers
When a disaster or emergency is declared under the Stafford Act or National Emergencies
Act and the HHS Secretary declares a public health emergency under Section 319 of the
Public Health Service Act, the Secretary is authorized to take certain actions in addition to
their regular authorities.

For example, under section 1135 of the Social Security Act, the Secretary may temporarily
waive or modify certain Medicare, Medicaid, and Children’s Health Insurance Program
(CHIP) requirements to ensure:

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1. sufficient health care items and services are available to meet the needs of
individuals enrolled in Social Security Act programs in the emergency area and time
periods
2. providers who give such services in good faith can be reimbursed and exempted
from sanctions (absent any determination of fraud or abuse)

Examples of these 1135 waivers or modifications include:

• Conditions of participation or other certification requirements

• Program participation and similar requirements
• Preapproval requirements
• Requirements that physicians and other health care professionals be licensed in the
State in which they are providing services, so long as they have equivalent licensing
in another State (this waiver is for purposes of Medicare, Medicaid, and CHIP
reimbursement only – state law governs whether a non-Federal provider is
authorized to provide services in the state without state licensure)
• Emergency Medical Treatment and Labor Act (EMTALA)
• Stark self-referral sanctions
• Performance deadlines and timetables may be adjusted (but not waived).
• Limitations on payment for health care items and services furnished to Medicare
Advantage enrollees by non-network providers

These waivers under section 1135 of the Social Security Act typically end no later than the
termination of the emergency period, or 60 days from the date the waiver or modification
is first published unless the Secretary of HHS extends the waiver by notice for additional
periods of up to 60 days, up to the end of the emergency period.

Information Curtesy of CMS website: 1135 Waivers | CMS

(https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertEmergPrep/1135-Waivers)
Resources:
1. 1135 Waiver at a Glance (https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertEmergPrep/Downloads/1135-Waivers-At-A-Glance.pdf)
2. 1135 Waivers (https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertEmergPrep/Downloads/CMS-Presentation-1135-Waivers.pdf)
3. AUTHORITY TO WAIVE REQUIREMENTS DURING NATIONAL EMERGENCIES
(https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertEmergPrep/Downloads/1135-Waivers-Authority.pdf)

Ethical Guidelines
The Institute of Medicine’s Guidance for establishing Crisis Standards of Care for use in disaster
situations offers a useful framework which fundamentally relies on the principle of justice.

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Ethical Values:
• Fairness: who receives what and at what point
• Professional Duty: do no harm, do not abandon
• Stewardship: allocating scarce resources; utilitarianism

Ethical Process Elements:

• Transparency: communication to stakeholders
• Consistency: nondiscrimination
• Proportionality: elevating response during emergency
• Accountability: acting upon duty to respond
During an emergency the following events require incorporation of sound ethical
considerations:
1. Triage: workforce members should be prepared to prioritize which residents to evacuate
first prior to or during a crisis
2. Allocation of Resources: workforce members should know what resources are available
during a crisis, where supplies are stored, and have the tools needed to determine how
scarce resources will be issued
3. Standards of Care: workforce members should be prepared to adjust their standards of
care during an emergency. Considerations include ensuring individuals are trained to
provide care normally outside of their professional practice
Here is the Link to the Minnesota Department of Health’s Crisis Standards of Care page.
Ethical Considerations for Crisis Standards of Care- Minnesota Dept. of Health
(https://www.health.state.mn.us/communities/ep/surge/crisis/ethical.html)

Infection Prevention and Control:

Infection prevention and control is required to prevent the transmission of communicable
diseases in all health care settings. Infection prevention and control demands a basic
understanding of the epidemiology of diseases; risk factors that increase patient susceptibility
to infection; and the practices, procedures and treatments that may result in infections.

The risk of acquiring a healthcare-associated infection is related to the mode of transmission of

the infectious agent (e.g. CDI, SSI, CRE, MRSA, etc.), the type of patient-care activity or
procedure being performed and the underlying patient's host defenses. Healthcare workers
should be vaccinated against preventable diseases such as hepatitis B. Personnel at risk for
exposure to tuberculosis should be screened per recommendations.

When an infection outbreak affects a broad population in the United States, the Centers for
Disease Control and Prevention (CDC), is responsible for making specific recommendations for
infection control measures in different circumstances and settings.

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• MDH Infection Prevention and Control

(https://www.health.state.mn.us/facilities/patientsafety/infectioncontrol/index.html))
• COVID-19 PPE and Source Control Grids (4/7/22) – This document was developed to
help facilities identify what level of PPE was needed bases on community transmission
level. https://www.health.state.mn.us/diseases/coronavirus/hcp/ppegrid.pdf

Crisis Staffing
Maintaining adequate staffing is essential to provide a safe environment for residents and staff.
Facilities should be prepared for varying levels of staffing shortages, have contingency staffing
plans in place, and ensure resident safety.

Health care facilities may need to implement crisis-level staffing strategies and the
identification of conventual, contingency and crisis staffing. It is up to the facility/agency to
determine their staffing level.

Conventional: This phase includes activation of the facility’s normal day-to-day protocols to fill
staffing gaps, including utilizing on-call staff, and leveraging resources from facility partners.
The quality of care provided to the residents is the highest practicable level of care to meet the
needs of the residents.

Contingency: This phase occurs when local resources are exhausted. It may include canceling
events or activities to balance workloads; readjusting facility schedules to allow for
maximization of in-house staff; adding incentives or bonuses for staff who take on additional
shifts; bringing on additional staff from outside of the facility (i.e., supplemental staff); and
using volunteers to serve nonclinical roles to assist with critical daily tasks.

Crisis: This phase occurs when there is significant staffing shortages and consists of
implementing large-scale changes to the way the facility provides care and conducts business.
Activities include leveraging statewide and federal resources. Staff must consider altered
standards and do the best they can with the resources available.

See MDH Long-term Care Contingency Staffing Plan (Template) and training webinar for
additional information. Long-Term Care Emergency Preparedness
(https://www.health.state.mn.us/communities/ep/ltc/index.html)

Volunteers
Use of volunteers can be part of day-to-day operations or part of an emergency. In either case
they need to be properly trained for their assigned job.

Local volunteers

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Minnesota Responds/Medical Reserve Corp is a partnership that integrates and engages local,
regional, and statewide volunteer programs to strengthen public health and health care, reduce
vulnerability, build resilience, and improve preparedness, response, and recovery capabilities.
Each Community Health Board in Minnesota has a Minnesota Responds program. MNResponds:
FAQ (https://www.mnresponds.org/faq.php)

All requests need to go through proper channels which MAY include the county Emergency
Operation Center and the State Emergency Operation Center.
Workers Comp and tort claim defense and indemnification are covered by the jurisdiction that
maintains the volunteers unless the volunteers are responding at the request of the
commissioner of health then they are covered by the state. Sec. 12.22 MN Statutes
(https://www.revisor.mn.gov/statutes/cite/12.22)

Liability insurance is covered by the requesting jurisdiction/facility.

State volunteers
This may happen depending on the situation like COVID-19 when the MN National Guard was
activated. Below was the consideration used during COVID-19.

Each situation will be different, and the consideration may change.

Prior to consideration for National Guard support, the facility must have exhausted the
resources available as outlined in the LTC Progression guidelines which includes having:
• Exhausted all internal staffing options, including payment of incentives, cross training of
positions, etc.
• Explored potential assistance from related facilities.
• Attempted to obtain assistance from Supplemental Nursing Agencies and have contracts
in place with multiple agencies.
• Attempted to obtain assistance from Public Health Agencies.
• Activated any Emergency Staffing MOU’s (Memorandums of Understanding) and
Memorandums of Agreement (MOA) which have been outlined in the facility Emergency
Plan.
• Contacted their trade associations for assistance.
• Contacted their assigned Regional Healthcare Coalition for assistance.
• Contacted their county emergency managers.
If all areas have been exhausted, and the application for assistance meets the criteria as
assessed by the LTC Response Team Crisis Manager, National Guard assistance may be an
option.

Sheltering in Place

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In certain situations, such as a tornado or chemical incident, your facility/agency may be better
off to stay and shelter in place. In an emergency, your facility/agency may be without telephone
or other communications, electric power, or water and sewer service for several days. The
facility/agency must be able to operate for at least 72 hours without outside assistance. Your
plan should include provisions for resident care (monitoring of medical conditions), facility
safety and security, food, water, medications, contact with first responders (fire, police, EMS,
etc.), public health, transportation, staff, lighting, temperature control, waste disposal, and
medical supplies.
The sheltering in place plan is not specific to the event requiring sheltering, instead, the plan
should contain the following:
• Plan in place describing how three days of non-perishable meals are kept on hand for
residents and staff. The Plan should include special dietary requirements.
• Plan in place describing how 72 hours of potable water is stored and available to
residents and staff
• Plan in place identifying 72 hours of necessary medications that are stored at the
facility and how necessary temperature control and security requirements will be met.
• Plan in place to identify staff that will care for the residents during the event including
any transportation needs that the staff might have and how the facility will meet those
needs
• Plan in place for an alternative power source, such as an on-site generator, and
describe how 72 hours of fuel will be maintained and stored. Alternate power source
plan provides for necessary testing of the generator
• Plan in place describing how the facility will dispose of or store waste and biological
waste until normal waste removal is restored
• Emergency Communications Plan in place, such as for cell phones, handheld radios,
pager, satellite phone, laptop computer for instant messaging, runners, etc
• Planning considerations given to the needs of residents, such as dialysis residents
• Planning considerations given to residents on oxygen
• Planning considerations given to residents using durable medical equipment such as
masks, nasal cannulas, colostomy equipment, g-tube, etc
See Appendix H for Facility Shelter in Place checklists and Response Items.

Evacuation
While evacuation is typically not preferred, there may be times when this option is safest for
the residents and staff. Due to the varied abilities of residents, evacuation can be a daunting
task without appropriate consideration and planning. Prior planning regarding how residents
will be transported, who will provide the transportation, what specialty types of vehicles will be
needed and where they will come from all need to be prearranged to maximize the safety of
residents and staff. Evacuation planning also includes determining what supplies, food, water,
medications, and other physical items will be needed to maintain safety. Pre-determined
locations should be identified and have an MOU created where residents can be taken that will

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adequately meet their needs. Identifying pre-determined locations and having discussions
ahead of time will ensure a smooth transition. Sample memoranda are provided to serve as
templates (See Appendix K). Additionally, it should be noted that having an evacuation
agreement with more than one facility would be appropriate. Traditionally, facilities often
choose the closest like facility with which to partner. However, a second facility some distance
away may be prudent if the closest facility may be similarly affected and unable to handle the
transfer request.
The following pages are specifically dedicated to looking at evacuation needs. If additional
evacuation and shelter-in-place planning resources are desired, please refer to the Health Care
Sheltering, Relocation, and Evacuation
(https://www.health.state.mn.us/communities/ep/surge/sheltering/index.html)
See appendix I for Evacuation Checklists.

Evacuation Transportation
The transportation plan should describe how the residents will be transported to the sheltering
facilities. It should include as an attachment any contracts or Memorandums of Agreement with
transportation companies, churches or ambulance services, or other transportation modality.
The transportation plan should include:
1. The number and types of vehicles required
2. How the vehicles will be obtained
3. Who will provide the drivers
4. Medical support to be provided for the resident during transportation. The following
support needs should be considered:
a. Residents who are independent in ambulation
b. Residents who require assistance with ambulation
c. Residents who are non-ambulatory
d. Residents with cognitive impairments
e. Residents with equipment/prosthetics (equipment/prosthetics should
accompany residents and should be securely stored in the designated mode
of transportation)
5. Estimation of the time to prepare residents for transportation
6. Estimation of the time for the facility to prepare for evacuation
7. Estimation of time for the resident to reach the sheltering facility
8. Detailed route to be taken to each sheltering facility if possible
9. Description of what items must be sent with the resident such as:
a. The resident’s medical record, which contains the medications being taken by
the resident, dosage, frequency of medication administration, special diets,
special care, etc
b. A three-day supply of medications (if possible)
c. Special medical supplies the resident may need
d. Other items such as clothing, incontinence products, etc

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10. The medical records should be provided to the receiving facility and remain with
the receiving facility until the resident is transferred back to the sending facility or to
another facility
11. Records should be maintained of which residents are transported to which facilities
See Appendix J for Evacuation Transportation

Evacuation Destination Information

The Evacuation Plan should describe where the residents will be transported. The receiving
facility should be appropriate for the level of care required for the residents being evacuated.
The plan should include as an attachment any contract, memorandum of agreement, or
transfer agreement the facility has with a receiving facility. The following should be considered
in the plan:
• Sleeping plan
• Feeding plan
• Medication plan
• Accommodations for relocated staff
• Number of relocated residents that can be accommodated at each receiving facility

Evacuation Staffing
The Staffing Plan should include how the relocated residents will be cared for at the sheltering
facility as well as the number and type of staff that is needed at the evacuating facility to help
evacuate the residents. This includes:
• Description of how care will be provided to relocated residents
• Identification of number and type of staff needed to evacuate the facility and to
accompany residents to the sheltering facility
• Plan for relocating facility staff
• A contingency plan if facility staff cannot make it into the shelter due to their
own family’s needs

Memorandums of Understanding
Health care facilities/agencies should consider memorandums of understanding (MOUs) with
organizations that can provide them resources and services during emergencies and disasters.
MOUs are established between hospitals, other health care providers and/or emergency
response agencies to identify their agreements to collaborate, communicate, respond, and
support one another during a disaster or other public health emergency. Understandings
regarding the incident command structure, resident, and resource management, processes, and
policies in place for requesting and sharing of staff, equipment, and consumable resources, as
well as payment, are generally addressed in a local mutual aid MOU.

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MOUs help facilities/agencies demonstrate and document compliance with Joint Commission
and State and Federal expectations for collaborative planning and disaster response. MOUs are
also a documentation asset when seeking federal reimbursement through FEMA after a
disaster.
MOUs are also used by facilities/agencies to document agreements with other organizations
and agencies to provide transportation, consumables (e.g., water, food), equipment, personnel
and many other resources and services that may be needed during a disaster event. These
MOUs help to document a facility’s/agency’s ability to respond and to sustain operations.
Examples include MOUs with:
• Local hospitals for resident transfer, supplies, equipment, pharmaceuticals, and
personnel
• Local nurse registry agencies, temporary agencies, and security personnel providers.
• Other local health care providers including clinics and LTC facilities for personnel,
supplies, equipment, and transportation
• Vendors and suppliers for health care and non-health care resources.
• County government for services including transportation and security; for supplies;
and for assistance in managing the treatment and transportation of staff and residents
• Third party payors to suspend lag time for payments
See Appendix K for MOU templates

Attachments and Documents

The following documents should be included as attachments to the Evacuation Plan, reviewed
and updates annually:
1. Sheltering agreements/MOUs between the facility and the receiving facility
2. Transportation agreements/MOUs between the facility and ambulance companies,
bus services, churches, etc
3. Documentation of any coordination between law enforcement, fire departments,
emergency manager, etc
See Appendix I/J for evacuation plans, checklists, and transportation agreements.

Recovery
Disaster and crisis planning are primarily focused on preparing and responding; however,
another critical component is the recovery phase. At this point the worst of the immediate and
acute crisis has passed, and a facility/agency can focus on returning to standard operations.
From a facilities/agency standpoint, recovery often means looking at the infrastructure of the
facility/agency and making determinations if the facility/agency is still operable and capable of
taking care of the residents. Recovery should be coordinated with others such as local
emergency management, financial personnel, public health, food delivery services, utilities, etc.
In other words, recovery involves taking a complete look not just at the physical structure, but

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also those types of needs that support the safe and effective operation of your facility/agency,
staff, and residents. Recovery is a fluid situation which may last months to years.
See Appendix L for consideration checklists for re-opening

Staff Care
During a crisis or disaster, additional help is often needed. One way to make it easier for staff to
stay at or report in to work, is to have a staff care plan. A staff care plan includes pre-
determined arrangements for staff members’ family and loved ones. Having this information
available allows staff to feel comforted that arrangements are made for their loved ones and
often increases the likelihood that staff will remain at or report in to work.
• Main family preparedness page: Disasters and Emergencies (https://www.ready.gov/be-
informed)
• How to build a household emergency kit: Build a Kit (https://www.ready.gov/kit)
• How to write a household plan: Make a Plan (https://www.ready.gov/plan)
• Fillable emergency communication card that folds to fit in the wallet: Make a Plan Form
(https://www.ready.gov/sites/default/files/2021-10/family-communication-
plan_fillable-card.pdf)
• Individuals with Disabilities: Individuals with Disabilities
(https://www.ready.gov/disability)
• Pets and Animals: Pets (https://www.ready.gov/pets)
• Seniors: Seniors (https://www.ready.gov/seniors)
• Do1Thing-Emergency Preparedness for Individuals and Businesses:
https://www.do1thing.com/
• MN Council on Disability:- Emergency Plan for People with Disabilities
(https://www.disability.state.mn.us/technical-assistance/emergency-
preparedness/emergency-plan-for-people-with-disabilities/)
• Red Cross - Prepare For Emergencies (https://www.redcross.org/get-help/how-to-
prepare-for-emergencies.html)

Behavioral Health
During an emergency it is important to consider behavioral health concerns. Behavioral health
includes the emotions and behaviors that affect your overall well-being. Behavioral health is
sometimes called mental health and often includes substance use. Just like physical health,
behavioral health has trained providers who can help you much like a physical health care
provider.
• WellnessMN (https://wellnessmn.org/)
• Disaster Behavioral Health and Emergency Preparedness
(https://www.health.state.mn.us/communities/ep/behavioral/index.html)

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• Regional Behavioral Health Coordinators (RBHC)

(https://www.health.state.mn.us/communities/ep/behavioral/rbhc.html)
• home | Workplace Health Promotion | CDC

Exercise, Evaluation, and Improvement Planning

For any plan to be useful, it needs to be tested periodically to identify gaps in the plan and
areas for improvement. Unless the plan is tested routinely, it is not truly a functional piece of
work, which is the goal of having an emergency operations plan. All disaster plans fail in some
capacity during a real-world incident. Regular preparedness exercises and training can help the
facility/agency to adapt the plan during an incident. For this reason, there should be an exercise
plan which includes both an evaluation piece, improvement planning, and trainings
The Centers for Medicare and Medicaid Services (CMS) Emergency Preparedness Requirements
state that LTC facilities/agencies must offer training on emergency procedures at least once
annually and must complete at least two exercises annually: one full-scale exercise that is
community or facility based and one additional exercise of the facility’s choice. See link for
requirements: CMS Emergency Preparedness Requirements by Provider Type.
See Appendix M for Exercise, Evaluation, and Improvement Planning Checklist
Recovery can take months to years and is part of the cycle for emergency preparedness.

Basic Exercise Requirements by facility/agency type per CMS Appendix Z:

Community based Addition exercise opposite

exercise every two one above. May be a second
Documentation of
Facility Type years or Individual full-scale exercise, mock
exercise, AAR
facility based functional disaster drill or tabletop
exercise exercise or workshop.

Annual Full-scale
SNF/ALF Annual additional exercise X
exercise

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Community based Addition exercise opposite

exercise every two one above. May be a second
Documentation of
Facility Type years or Individual full-scale exercise, mock
exercise, AAR
facility based functional disaster drill or tabletop
exercise exercise or workshop.

AL Group Homes Annual Full-scale

Annual additional exercise X
– ICF/IID exercise

Home Care X X X

Annual Full-scale
Hospice inpatient Annual additional exercise
exercise

Hospice
X X X
outpatient

Variability in Requirements
For inpatient providers:
(inpatient hospice facilities, PRTFs, hospitals, LTC facilities*, ICFs/IID, and CAHs): The types of acceptable
testing exercises are expanded. Inpatient providers can choose one of the two annually required testing
exercises to be an exercise of their choice, which may include one community-based full-scale exercise
(if available), an individual facility-based functional exercise, a mock disaster drill, or a tabletop exercise
or workshop that includes a group discussion led by a facilitator.

*NOTE: For LTC facilities, while the types of acceptable testing exercises was expanded, LTC facilities
must continue to conduct their exercises on an annual basis.
Facilities must conduct exercises to test the emergency plan, which for LTC facilities also includes
unannounced staff drills using the emergency procedures.

For outpatient providers:

(ASCs, freestanding/home-based hospice, PACE, HHAs, CORFs, Organizations (which include Clinics,
Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and
Speech-Language Pathology Services), CMHCs, OPOs, RHCs, FQHCs, and ESRD facilities): Facilities are
required to only conduct one testing exercise on an annual basis, which may be either one community-
based full-scale exercise, if available, or an individual facility-based functional exercise. The opposite
years (every other year opposite of the full-scale exercises), these providers may choose the testing
exercise of their choice, which can include either another full-scale, individual facility-based, a mock
disaster drill (using mock patients), tabletop exercise or workshop which includes a facilitator.

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Regional Resources and Support Agencies

The following map will assist LTC facilities/agencies in determining to which region they belong.
See Appendix N for links to regional and coalition specific contact information.

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List of Appendixes and Annexes

Appendix/Annex Description
Appendix A.1 CMS Emergency Preparedness Checklist
Appendix A.2 CMS Rule by Provider Type Definitions
Appendix A.3 Table Requirements by Providers
Appendix A.4 CMS Updated Emergency Preparedness Guideline
Appendix A.5 MDH Crosswalk
Appendix A.6.1 Supplemental Document for Group Homes, Hospice, and Home Care
Appendix A.6.2 Resident Emergency Preparedness Information
Appendix B Hazard Vulnerability Analysis and Tool
Appendix C.1 Communications
Appendix C.2 External and Internal Contact Roster Excel Spreadsheet
Appendix D.1 Incident Command System (ICS) Organization Chart
Appendix D.2 HCIS Incident Action Plan
Appendix D.3 ICS Guide – Digging Deeper
Appendix D.4 Extra Job Action Sheets
Appendix E Facility/Agency Contact Lists
Appendix F Building Specific Information
Appendix G HIPAA Waiver Toolkit
Appendix H Facility Shelter in Place Checklists and Recovery Items
Appendix I Evacuation Checklists
Appendix J Evacuation Transportation
Appendix K MOU Templates
Appendix L Recovery Checklists
Appendix M.1 Exercise, Evaluation, and Improvement Planning Checklist and AAR/IP
Appendix M.2 AAR-IP Short Template
Appendix M.3 AAR-IP Medium Template
Appendix M.4 CMS AAR Template
Appendix N Regional Contacts and Important Resources
Annex A Emergency Notification of Administrator
Annex B Bioterrorism Threats
Annex C Bomb Threat
Annex D Chemical Spills

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Appendix/Annex Description
Annex E Electrical Power Outage
Annex F Apartment Evacuation
Annex G Fire Guidance
Annex H Severe Weather
Annex I Cybersecurity
Annex J Flood Guide
Annex K Missing Resident
Annex L Emergency Shut Down
Annex M Emerging Infectious Disease
Annex N Active Shooter
Annex O Radiological

The attachments contained within the Appendixes and Annexes are considered templates. To
make the documents facility specific, facilities will need to adapt the templates.

Acronyms
Acronym Description
AAR After Action Report
AL Assisted Living
ALF Assisted Living Facility
CDC Centers for Disease Control and Prevention
CEO Chief Executive Officer
CFLOP Command, Finance Logistic, Operations, Planning
CMS Centers for Medicare & Medicaid Services
COOP Continuity of Operations Plan
CSC Crisis Standards for Care
DOC Department Operations Center
DON Director of Nursing
EM Emergency Management
EMS Emergency Medical Services
EMTALA Emergency Medical Treatment and Labor Act
EOC Emergency Operations Center
EOP Emergency Operations Plan

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Acronym Description
FEMA Federal Emergency Management Agency
HAI Healthcare Associated Infections
HHS Health and Human Services
HICS Hospital Incident Command System
HPP Hospital Preparedness Program or Health Care Preparedness Program
HIPAA Health Insurance Portability and Accountability Act
HHS Health and Human Services
HSEEP Homeland Security Exercise & Evaluation Program
HSEM Homeland Security & Emergency Management
HVA Hazard Vulnerability Analysis
HVAC Heating, Ventilation & Air Conditioning
IAP Incident Action Plan
IC Incident Command or Infection Control
ICAR Infection Control Assessment and Response Program
ICF/IID Intermediate Care Facilities for Individuals with Intellectual Disabilities
ICS Incident Command System
IMS Incident Management System

IP Improvement Plan
IT Information Technology
JAS Job Action Sheets
LTC Long-term Care
MDH Minnesota Department of Health
MHA Minnesota Hospital Association
MOA Memorandum of Agreement
MOU Memorandum of Understanding
NFPA National Fire Protection Association
NICS Nursing Home Incident Command System
OSHA Occupational Safety and Health Administration
PFA Psychological First Aid
PHPC Public Health Preparedness Consultant
PIO Public Information Officer
POC Point of Contact

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Acronym Description
PPE Personal Protective Equipment
RHPC Regional Healthcare Preparedness Coordinator
SNF Skilled Nursing Facility

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