K48 – There is a written plan for the protection of all patients and for their evacuation in the event of an emergency.

NFPA Standard: 101, 19.7.11

The administration of each health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator’s position or at the security center.

NFPA Standard: NFPA 99, 16-3.11

Nursing homes shall comply with the provisions of Chapter 11 for emergency preparedness planning, as appropriate.

NFPA Standard: NFPA 99, 11-5.3.9

Each organizational entity shall implement one or more specific responses of the emergency operations plan during each year, at least one of which shall rehearse mass casualty response for health care facilities with emergency services, disaster stations, or both.

19 CSR 30-85.022(33) Fire Drills and Emergency Preparedness.

(A) All facilities shall have a written plan to meet potential emergencies or disasters and shall request consultation and assistance annually from a local fire unit for review of fire and evacuation plans. If the consultation cannot be obtained, the facility shall inform the state fire marshal in writing and request assistance in review of the plan. An up-to-date copy of the facility’s entire plan shall be provided to the local jurisdiction’s emergency management director. II/III

(B) The plan shall include, but is not limited to—
1. A phased response ranging from relocation of residents to an immediate area within the facility; relocation to an area of refuge, if applicable; or to total building evacuation. This phased response part of the plan shall be consistent with the direction of the local fire unit or state fire marshal and shall be appropriate for the fire or emergency;
2. Written instructions for evacuation of each floor including evacuation to areas of refuge, if applicable, and floor plan showing the location of exits, fire alarm pull stations, fire extinguishers, and any areas of refuge;
3. Evacuating residents, if necessary, from an area of refuge to a point of safety outside the building;
4. The location of any additional water sources on the property such as cisterns, wells, lagoons, ponds, or creeks;
5. Procedures for the safety and comfort of residents evacuated;
6. Staffing assignments;
7. Instructions for staff to call the fire department or other outside emergency services;
8. Instructions for staff to call alternative resource(s) for housing residents, if necessary;
9. Administrative staff responsibilities; and
10. Designation of a staff member to be responsible for accounting for all residents’ whereabouts. II/III

(C) The written plan shall be accessible at all times and an evacuation diagram shall be posted on each floor in a conspicuous place so that employees and residents can become familiar with the plan and routes to safety. II/III

Dave’s Memo: The Standard says you “shall implement one or more specific responses… at least one of which shall rehearse mass casualty response”. Review your evacuation plans. Your plan needs to address a phased response, including evacuation to areas of refuge to total evacuation. You must implement one or more aspects of the emergency preparedness plan each year in accordance with the requirements above. Be sure your plan includes all the elements listed in (B) 19 CSR 30-85.022(33) Fire Drills and Emergency Preparedness

To consider an exercise a drill, the following aspects are typically incorporated and documented: a general overview of the scenario, activation of the disaster plan, evaluation of all involved participants/departments, a critique session following the drill, and any identified follow-up training to correct or improve any deficiencies.

If you plan an evacuation drill to the outside, please be aware of time of year and weather conditions.