Protecting Nursing Home Residents in Disasters: The Urgent Need for a New Approach Amid Mounting Climate Warnings

Nearly two decades ago, Hurricane Katrina exposed major gaps in disaster preparedness in nursing homes, whose residents are at the highest risk of harm because of their physical and psychological vulnerabilities.^1,2 Government reports and research documented chaotic evacuations and dangerous sheltering-in-place conditions resulting from poorly developed and executed disaster preparedness plans.^3–5 A 2006 report from the Department of Health and Human Services’ Office of the Inspector General (OIG) discussed numerous cases of inadequate preparedness in nursing homes across five hurricane-prone U.S. states, even though 94% of those audited technically met the standards set by the Centers for Medicare and Medicaid Services (CMS) at the time.⁶

The reports gave rise to a number of federal, state, and local efforts to shore up regulatory requirements and operational practices in nursing homes, particularly in disaster-prone states.^7–9 Emergency management is now recognized as a critical element of nursing home operations, and preparedness appears to have improved,^10–11 but government audits, research, and repeated disaster experiences, provide evidence of continuing gaps.¹²

In the article “Evaluating California Nursing Homes’ Emergency Preparedness for Wildfire Exposure,” Festa et al. raise additional concerns about nursing home preparedness.¹³ The authors identified 495 nursing homes across California (42%) that were within 5 kilometers of a state-designated “wildfire risk area” and found that the risk-exposed facilities were more likely to have been cited for deficient emergency preparedness practices than nursing homes outside these risk areas.

The greatest number of citations concerned implementation of requirements for emergency and standby power systems, a critical area given the dependence of nursing home residents on electrical equipment and indoor temperature control. In 2017, after Hurricane Irma in Florida, at least 12 nursing home residents died of heat exposure after their facility lost the power to its air conditioning system.¹⁴ This led to state legislation in Florida requiring all nursing homes and assisted living communities to have generators or other sources of power to maintain cool temperatures. In Texas, in 2021, dozens of nursing homes and assisted living communities were required to evacuate because of freezing temperatures when Winter Storm Uri caused near-statewide electrical blackouts.

In the wildfire study, numerous citations also were issued for deficiencies in disaster plan testing and exercises, a critical aspect of determining whether a plan is effective, and for inadequate preparedness policies and procedures and communications plans. The study overall highlighted the limitations of nursing home regulations, with the authors concluding that federal preparedness requirements may not be effective in ensuring adequate wildfire response in nursing homes. They proposed an approach modeled on principles of “responsive regulation.” It would establish regulatory procedures centering on nursing homes’ actual risks and risk-specific preparedness. Additionally, this approach would involve local stakeholders, not just nursing homes and regulatory officials. As it is, CMS requires nursing homes to assess all hazards they are reasonably expected to confront, in addition to the vulnerabilities of their residents, and to develop comprehensive plans to address each of those risks.¹⁵ With a responsive regulation approach, partnerships would be formed, potentially at CMS’ direction, between nursing homes and their local emergency and safety officials. Through these partnerships with officials most knowledgeable about local threats and risks, nursing homes would be expected to develop emergency preparedness plans that best suit their circumstances. Oversight would be risk-based and occur at the local level, though CMS would keep its enforcement role to address higher level noncompliance.

This is a novel proposal, though recognition of the need for local involvement in emergency preparedness is not new. The 2006 OIG report recommended that CMS encourage more communication and collaboration between nursing homes and state and local emergency officials, and CMS agreed in its response.⁶ The same issue emerged prominently in a disaster preparedness summit convened in Florida in 2007 that brought together state and federal regulators, emergency managers, and representatives of nursing homes from across the U.S. Gulf Coast.^8,9

To this day, however, these relationships have proven to be difficult to forge and maintain, with CMS playing an indecisive role. Federal regulations outlined in 2019 stated that while emergency management agencies bear the responsibility of coordinating community-level disaster preparedness, nursing homes would be required to document their efforts to contact emergency managers in their areas to help integrate themselves into community-level disaster planning. However, last year, CMS removed this requirement for documentation, with the new language stating only that nursing homes “must have a process” to engage in collaborative disaster planning.

Florida’s experience is instructive in this regard. As a state, Florida requires nursing homes to submit their emergency management plans to county-level emergency management officials annually for review and approval – a step that ensures some level of local collaboration. However, in a 2020 OIG audit of disaster preparedness in Florida nursing homes, a sample of local emergency managers described numerous collaboration challenges.¹⁶ The challenges included a lack of resources to complete the required nursing home plan reviews and confusion about what requirements to use to assess the plans. The OIG recommended that the Florida agency responsible for enforcing nursing home regulations, the Agency for Health Care Administration, work more closely with local emergency managers to develop a process to monitor submissions from nursing homes, clarify responsibilities, and provide more information about inspection results related to disaster preparedness. The state agency responded that it already provided sufficient information to local officials through multiple training opportunities offered each year.

Our research team interviewed Florida nursing home administrators after Hurricane Irma, in 2017, and found related evidence that relationships were strained between nursing homes and local emergency managers in many counties.¹⁰ To be sure, some nursing home administrators reported professional and productive interactions with local officials involved with disaster preparedness and other community-based organizations. As a result, they perceived they were more successful at anticipating their facility and resident needs, and those who faced unexpected challenges during the hurricane had local resources to call upon for help. However, many others complained that the local preparedness and public safety officials in their counties lacked longevity in their positions or had multiple other job tasks and were ignorant of nursing home responsibilities and operations and their disaster preparedness challenges. And there were other nursing home administrators who seemed to be unaware of any community-level planning resources or had little time or incentive to engage with them and simply submitted their plans for annual review with little to no interaction.

The responsive regulation approach described by Festa et al. involves local officials working more closely with nursing homes to ensure their plans address the specific risks they face. It would seem to be welcome to nursing homes who have had contentious or unproductive experiences with local preparedness officials or have received no local guidance but continue to receive preparedness-related deficiencies during their annual state inspections.

It is unclear how such an approach would be operationalized, given that CMS has limited its role to encouraging nursing homes to engage in community-level disaster preparedness collaboration. However, our interviews with nursing home administrators after Hurricane Irma showed that while it can be contentious, collaboration between nursing home and emergency officials is possible. Many of these collaborations were possible because of relationships formed between state disaster officials and statewide nursing home industry groups during and after the disaster summit meeting of 2007. This points to the key role that states could play, to identify successful nursing home/community partnerships and promote these as best practices, along the lines of a responsive regulation approach. This is an appropriate role for a state, given the statewide systems already in place for disaster preparedness and nursing home quality assurance. States have the ability to establish their own regulations for nursing homes, as long as they don’t undercut existing federal regulations. The all-hazards approach is still needed to protect residents in cases of unexpected risks, such as chemical spills, but forging stronger community ties would benefit nursing homes in these cases, as well as in the more frequently occurring events. Such efforts will require considerable state and local leadership and resources, but evidence is rapidly accumulating of the increased frequency and severity of weather-related disasters, such as Hurricane Ian in Florida, Hurricane Ida in Louisiana, Winter Storm Uri in Texas, flooding in Kentucky, and wildfires in California. The evidence tells us these investments are necessary and justified to protect individuals who are among the most vulnerable to harm when disaster strikes.