CMS defines “emergency/disaster” as an event that can affect the facility internally as well as the overall target population or the community at large or community or a geographic area(1). COVID-19 certainly meets that definition. Even if your facility has not experienced an outbreak of COVID-19, it is important to reassess your emergency preparedness and response plans and make adjustments based on what is currently known about the virus and current guidance on outbreak response and management.

The Emergency Preparedness Program describes a facility’s comprehensive approach to meeting the health, safety, and security needs of the facility, its staff, their patient population and community prior to, during, and after an emergency or disaster. The program encompasses four core elements (see below) and must be updated at least annually. If you haven’t already, visit the ASPR Technical Resources, Assistance Center, and Information Exchange (TRACIE) for a plethora of tools and resources relative to preparedness and response. Consider how COVID-19 has affected your plan in each of these areas.

  1. Emergency Plan based on a Risk assessment and incorporates an all hazards approach

At what rank is Infectious Disease Outbreak for your facility? Should it be higher on the list of potential hazards? The Emergency Plan should be updated accordingly to address the extremely high probability that your facility could be impacted by COVID-19. Consider staffing contingency plans, supply chain resources, PPE availability and conservation, communication protocols, cohorting, fatality management, etc. If your facility experienced an outbreak earlier in the pandemic, update plans based on lessons learned. Ensure your plans include succession planning and a clear chain of command should leadership be exposed or become ill. Healthcare facilities in areas with high levels of community transmission recommend identifying and training at least three levels to provide relief should those with primary or secondary responsibility for each position be unable to work(2).

  1. Policies and Procedures

Update Infection Prevention and Control Policies and Procedures, along with PPE use protocols and conservation techniques. Identify specific ways to maintain physical distancing and address group activities and communal dining. Consider use of Telemedicine/Virtual Medical Care and how those services are used and provided during the PHE. Review and update workforce policies including screening, exposure, contact tracing and return to work procedures.

  1. Communication Plan

Update workforce/volunteer contact information and verify emergency contact information for all residents. Know your local, state, and federal notification and data reporting requirements and develop and distribute information on mitigation efforts and actions to be taken if someone becomes symptomatic or tests positive.

  1. Training and Testing Program

Ensure employees and volunteers are trained in the plan and specific COVID related updates in addition to training on infection prevention, including information about standard and transmission-based precautions and proper hand hygiene, etc.

Above all, your emergency preparedness and response plan should be unique and tailored to your facility’s population and operational needs. COVID-19 will likely be with us for some time and while it is imperative that we turn our attention toward mitigating the effects of the virus, it is just as important that we remain prepared for other potential disasters in tandem.


Would your facility benefit from an expert review of the Emergency Preparedness Plan? Contact Proactive for more information on how we can support you in compliance with Emergency Preparedness and COVID-19 outbreak prevention and management.




Blog by Eleisha Wilkes, RN, RAC-CTA, Proactive Medical Review

Click here to learn more about Eleisha and the rest of the Proactive team.