The Commonwealth of Massachusetts

Executive Office of Health and Human Services
Department of Public Health
Center for Quality Assurance and Control
99 Chauncy Street, 2nd Floor, Boston, MA 02111
617-753-8000

DEVAL L. PATRICK
GOVERNOR
TIMOTHY P. MURRAY
LIEUTENANT GOVERNOR
JUDYANN BIGBY, MD
SECRETARY
PAUL J. COTE, JR.
COMMISSIONER	
Circular Letter:  DHCQ 07-02-473

TO:         Long-Term Care Administrators

FROM:   Paul Dreyer, Ph.D., Associate Commissioner

DATE:    February 7, 2007

RE:         Emergency Preparedness at Long Term Care Facilities

Hurricane Katrina and the Mother’s Day Flood of spring 2006 have together reinforced the need for all of us in health care to plan for a variety of local disaster scenarios, as well as for a possible avian flu pandemic.  During the past year the Department and the Division of Health Care Quality have been working with providers to improve our ability to respond to such events. 

The purpose of this circular letter is to introduce a planning tool to use in developing emergency preparedness plans.  Please use this guide to review your facility’s emergency preparedness plan. The tool includes endnotes referencing State regulations, Federal conditions of participation, and other professional sources for each of the indicated preparedness items. Note that those State and Federal references in this document are minimally required items to be addressed in a LTC facilities emergency plan. You are directed to consult with your local Emergency Management Director, and the many provider organizations and associations which have excellent reference material and standards to further assist in your efforts to achieve an All Hazard readiness state of preparedness.

This document titled, “All Hazard Emergency Planning: Provider Attestation tool”, will be provided to the Administrator at the FY’ 07 annual recertification entrance conference by the team coordinator. (Thereafter, it will be applied every other year.) Surveyors will ask the administrator to complete, sign and return this document to the team coordinator by the morning of the second day of survey. No changes to the already required survey protocols required regarding this subject matter will occur, as surveyors will conduct the routine survey procedures regarding preparedness as they have been doing. Use of this document will facilitate facility self-assessment and surveyor analysis of facility readiness, consistent with the following requirements: 

Massachusetts code of regulations 105 CMR 150.015(E)(1) which states: Every facility shall have a written plan and procedures to be followed in case of fire, or other emergency, developed with the assistance of local and state fire and safety experts, and posted at all nurses' and attendants' stations and in conspicuous locations throughout the facility.

And, Federal Code of regulations 42 CFR 483.75(m)(1) which state:  The facility must have detailed written plans and procedures to meet all potential emergencies and disasters, such as fire, severe weather, and missing residents. 

This document containing references to the required State and Federal LTC preparedness regulations and conditions found at 105 CMR 150 and 42 CFR 483 Subpart B, was developed as a baseline guide to the Massachusetts LTC industry. It is the responsibility of each licensed entity to ensure its own readiness to protect its residents from any and all hazards, especially those for which it is most vulnerable, as indicated by a facility specific hazard vulnerability analysis. Input into the development of the first version of this document was obtained from various sources including feedback from representatives of the Massachusetts Extended Care Federation, Central DPH Emergency Preparedness and Massachusetts Emergency Management Agency.