DAL 15-13: Evacuation Planning

December 23, 2015

DAL 15-13: Evacuation Planning

Dear Adult Care Facility Administrator:

New York State Department of Health regulations at 18 NYCRR Sections 487.12 and 488.12 require each Adult Care Facility (ACF) to have a written emergency plan detailing the procedures necessary to protect residents and staff in the event of an actual or threatened emergency or disaster.

Therefore, it is imperative that at the time of pre-admission interviews with prospective residents, operators must first determine if the facility can meet the physical needs of the applicant. Admission determinations should include consideration of the current Disaster and Emergency Plan (the plan), and whether an applicant's need for assistance with evacuation, as well as those of the other residents, can be safely met.

Physical plant features and requirements must also be considered when developing and revising plans as certain licensure types must comply with various regulatory and life safety codes along with the New York State and local codes Occupancy Group I-1 or equivalent, in order for residents to live on various floors and units within the dwelling.

In recognition of a changing ACF population that has become increasingly frail, the Department encourages providers to refer to this guidance when developing and updating their existing plan.

  1. Plan Development: The plans must specify:
    • Current procedures for evacuation, (487.12(b) (2) (v) and 488.12 (c) (2) (iv));
    • Staff responsibilities for implementing the plan (487.12(b) (1), 488.12(c) (1) and 1001.14(d); and
    • Communication of components of the plan to those responsible for implementation and oversight (487.12(b)(ii) and (4); and 488.12(c)(ii) and (4).
  2. Minimum Requirements: At a minimum plans should include:
    • The name and room number of the resident(s) who require assistance;
    • The type of assistance each resident needs, including any equipment:
    • The number of staff needed to move the resident to a safe location;
    • Specific staff assignments for each shift;
    • The site of the immediate, designated safe location and the site of the long-term, designated safe location (such as beyond the first fire door);
    • Procedures to evacuate residents who cannot climb or descend stairs, and who are chair-fast or bed-fast, including the use of elevators if permitted by the local fire department;
    • Procedure for progressive evacuation if it is being used, (e.g., next zone, two zones away, fire tower stairs);
    • Procedures for and suitable equipment needed to move residents who require assistance in the event of power loss, which will directly impact elevator access;
    • Resident specific transportation needs (i.e. ambulance, ambulette, van, bus), and how this will be communicated to transport personnel. [Refer to the Transportation Assistance Levels (TALs) on the Health Commerce System (HCS) at HCS/My Content/Documents by Group/Health Care (ACFs)/Preparedness/Resources/Transportation Assistance Levels (TALs)];
    • How and who (by title) decides when to execute a partial or full evacuation; and
    • Relevant contact information, by title (not name) with the phone number, for:
      • Local Authority Having Jurisdiction (AHJ), who is the chief elected official, office or position having the statutory authority to recommend/order an evacuation;
      • County Office of Emergency Management (OEM);
      • Public Safety (e.g. police, fire department); and
      • Local government (village, town, city, county).
  3. Resident Specific Considerations:
    • Visual and hearing impairments;
    • Required medical equipment;
    • Wheelchair bound residents;
    • Chair-fast residents (ALP);
    • Mechanical lifts;
    • Level of cognition: Special Needs Assisted Living Residences (SNALR) and other facilities admit and retain residents with dementia who, due to impaired cognitive functioning, may require significant guidance and assistance to evacuate;
    • Level of acuity: EALRs may have residents with higher medical or clinical needs; and
    • Ability of a resident to take direction.
  4. Additional Actions:
    • Review the facility's plan with all staff at least quarterly and with any/all updates;
    • Maintain 24/7 staffing adequate in number and training to effectively evacuate residents in an emergency;
    • Conduct drills of the Disaster and Emergency Plan: consider increasing the frequency of evacuation drills based on the complexity of the plan;
    • Provide a copy of the plan to the local Fire Department (FD) and AHJ;
    • Incorporate a regular assessment of the plan as part of the Quality Assurance Program;
    • Continually review and update the plan to reflect the needs of residents and staffing patterns;
    • Communicate any updates to staff and the applicable entities, and provide copies as required.

Please be reminded that if the ACF is part of a mutual aid plan, the Disaster and Emergency Plan must include the ACF's role/participation in the mutual aid plan, which includes accepting residents from other facilities. As always, the Disaster and Emergency Plans will be reviewed at the time of survey.

If you have any questions regarding this, you may contact: evacupdate@health.ny.gov or acf.info@health.ny.gov. Thank you for your continued commitment to strengthen emergency planning.


Valerie A. Deetz, Director
Division of Adult Care Facility and Assisted Living Surveillance