Smarter HR SolutionsHouston, TX
- What they do
- Compliance consulting
- Who they help
- Its website offers consulting for employee handbooks, HR policies, HR compliance audits and OSHA written programs.
- Standards
- Pricing
- Not published
Emergency Action Plan
An Emergency Action Plan is the written procedure OSHA requires when another standard calls for one, most commonly the fire extinguisher, fixed extinguishing system, and process safety standards.
It tells employees how to report an emergency, which exit routes to take, who stays behind to shut down critical operations, how everyone is accounted for after evacuation, and who performs rescue or medical duties. Employers with more than ten employees must keep it in writing at the workplace; smaller employers may communicate it orally.
The plan usually travels with a Fire Prevention Plan (1910.39) and an alarm system description (1910.165). Accreditors in health care and human services (CARF, ACHC, CHAP, Joint Commission) ask for an emergency operations or preparedness plan that goes well beyond OSHA's six elements, so many organizations keep one document that satisfies both.
Also called: EAP, Emergency evacuation plan, Fire and emergency plan
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Who requires it, and what each one says.
| Source | Applies when | What it requires | Status |
|---|---|---|---|
| OSHA Emergency action plans 29 CFR 1910.38(a) to (c) | Another OSHA standard requires an EAP | A plan covering the six minimum elements; written, kept in the workplace and available to employees where the employer has more than ten employees; oral otherwise. Legally required. | Mandatory |
| OSHA Emergency action plans, alarm, training and review 29 CFR 1910.38(d) to (f) | Always when an EAP is required | An employee alarm system; designated and trained evacuation assistants; review of the plan with each employee at initial assignment, when duties change, and when the plan changes. Legally required. | Mandatory |
| OSHA Portable fire extinguishers 29 CFR 1910.157(a) | Extinguishers are provided but employees are expected to evacuate immediately | Where extinguishers are provided but not intended for employee use, an EAP and fire prevention plan meeting 1910.38 and 1910.39 limit the extinguisher requirements to paragraphs (e) and (f). An option that reduces extinguisher duties, and the trigger for most offices and retail, not a standalone mandate. | Implied |
| CMS emergency preparedness conditions of participation 42 CFR 484.102 (home health), 418.113 (hospice), 482.15 (hospitals), 483.73 (LTC) | You are a Medicare-certified provider | An all-hazards emergency preparedness plan with risk assessment, policies and procedures, communication plan, and training and testing, reviewed at least every two years. Legally required as a condition of payment. | Mandatory |
| CARF accreditation standards (ASPIRE to Excellence, all programs) CARF Standards 1.H.5 and 1.H.7 | You seek or hold CARF accreditation (any program) | Written emergency procedures for fires, bomb threats, natural disasters, utility failures, medical emergencies and violent or threatening situations, covering when to evacuate or shelter in place, complete evacuation, accounting for all persons, emergency phone numbers and notifying authorities. An unannounced test of each procedure at least annually, on each shift, at each location, analyzed and documented in writing. Accreditation requirement. | Mandatory |
| ACHC and CHAP accreditation standards (emergency preparedness) ACHC HH7-3A to HH7-3E and HH7-5A.01; CHAP EP.1 (home health), HSEP.2.D (hospice), HCEP.1 (home care); 42 CFR 484.102 and 418.113 | You seek or hold ACHC or CHAP accreditation | A written emergency preparedness plan. For Medicare deemed status it is the CMS all-hazards plan with risk assessment, policies and procedures, communication plan, and training and testing, reviewed at least every 2 years; CHAP home care requires a written emergency preparedness plan without Medicare. ACHC also requires office fire and safety management with an annual fire drill. Broader than, and not the same document as, an OSHA 1910.38 Emergency Action Plan. Accreditation requirement. | Mandatory |
Required sections
- Procedures for reporting a fire or other emergency (1910.38(c)(1))
- Emergency evacuation procedures, type of evacuation, and exit route assignments (1910.38(c)(2))
- Procedures for employees who remain to operate critical plant operations before evacuating (1910.38(c)(3))
- Procedures to account for all employees after evacuation (1910.38(c)(4))
- Procedures for employees performing rescue or medical duties (1910.38(c)(5))
- Name or job title of every employee who may be contacted for more information (1910.38(c)(6))
- Description of the employee alarm system and distinctive signals (1910.38(d), 1910.165)
- Designation and training of evacuation assistants (1910.38(e))
- Plan review triggers: initial assignment, change in responsibilities, change in the plan (1910.38(f))
- Fire prevention plan elements if combined (1910.39, single source)
- For CMS-certified providers: all-hazards risk assessment, communication plan, subsistence needs, continuity, staff training and testing schedule (42 CFR emergency preparedness CoPs, single source)
What the examiner asks for
Written planThe current EAP with date, site maps with exit routes, and the alarm description. Safety consultants, fire protection engineers, the employer
AttestationRecord that each employee reviewed the plan at assignment and after changes; evacuation assistant training rosters. Policy tools, LMS, HR onboarding checklists
Operational recordsDrill logs with date, shift, time to evacuate, issues found and corrective actions; alarm test records. The employer; safety consultants; accreditation consultants for CARF and CMS
Technical controlsAlarm system inspection and test records (1910.165(d)); emergency lighting tests. Fire alarm service contractors
Change log.
2024-02-16CMS Appendix Z interpretive guidance for emergency preparedness updated.
2019-11-29CMS burden-reduction rule changed emergency preparedness review to every two years for most provider types and reduced training frequency.
2017-11-15CMS emergency preparedness conditions of participation enforced for all 17 provider and supplier types.
2002-11-07OSHA rewrote 1910.38 in plain language as part of the exit routes rule revision; requirements unchanged in substance.
Where this document is required.
Where this document gets checked.
No one certifies a document like this on its own. It is read during the audits and inspections below, and by the agency behind each rule.
| Where it is looked at | Who looks at it |
|---|---|
| ACHC/CHAP | ACHC and CHAP surveyors employed or contracted by each accreditor, typically clinicians with home care or hospice experience. Surveys for Medicare deemed programs are unannounced |
| CARF | CARF surveyors, who are peer professionals employed in accredited or comparable organizations, trained and assigned by CARF. Surveys are scheduled and on site for two to three days |
| OSHA written programs | OSHA compliance safety and health officers, or State Plan inspectors (government inspection). No certification exists; voluntary recognition programs such as VPP and SHARP involve OSHA or consultation program evaluation |
Consultants.
Firms that name these standards in their own material.
Listed in random order, reshuffled each time the page loads. Firms that pay for a listing are shown at the top, labeled Sponsored.
Passio PEO and HR ConsultingEnglewood, CO, USA
- What they do
- Compliance consulting
- Who they help
- Its website offers consulting for OSHA compliance, Employee handbooks and HR policies, Employment law compliance, Harassment prevention training.
- Standards
- Pricing
- Not published
GreenLine HR Consulting LLCMeadville, PA, USA
- What they do
- Compliance consulting
- Who they help
- Its website offers consulting for OSHA compliance, Employee handbooks and HR policies, Employment law compliance, HR compliance audit.
- Standards
- Pricing
- Not published
Upstream Solutions, LLCUSA
- What they do
- Compliance consulting
- Who they help
- Its website offers consulting for OSHA compliance, Employee handbooks and HR policies, Employment law compliance.
- Standards
- Pricing
- Not published
Atlantic Health StrategiesWest Palm Beach, Florida, USA
- What they do
- Compliance consulting
- Who they help
- Its website offers consulting for CARF, HIPAA, 42 CFR Part 2, Joint Commission.
- Standards
- Pricing
- Not published
Circa Behavioral Healthcare SolutionsMission Viejo, California, USA
- What they do
- Compliance consulting
- Who they help
- Its website offers consulting for CARF, HIPAA, Joint Commission.
- Standards
- Pricing
- Not published
MVP Consulting GroupLong Beach, California, USA
- What they do
- Compliance consulting
- Who they help
- Its website offers consulting for CARF, HIPAA, AAAASF, AAAHC, CMS and more.
- Standards
- Pricing
- Not published
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What people ask.
We have eight employees. Do we need a written plan?
OSHA allows oral communication of the plan at ten or fewer employees. You still need to cover all six elements and be able to show a compliance officer that employees know them. Most small employers write it anyway because it is one page.
Is one plan enough for several sites?
Each site needs its own exit routes, assembly points, and contact names. A single template with a site appendix is the common approach.
How often do we have to drill?
OSHA does not require drills under 1910.38, though it recommends them. CMS requires at least one exercise a year for outpatient providers such as home health and home-based hospice, and two a year for inpatient providers such as hospitals and inpatient hospice, and CARF requires unannounced drills on each shift at each location. Check the standard that applies to you.
Does the EAP cover active shooter or severe weather?
OSHA's six elements are written around fire. Most current plans add sections for shelter-in-place hazards. CMS requires an all-hazards approach for certified providers.