A hospital is an institution primarily engaged in providing, by or under the supervision of physicians, inpatient diagnostic and therapeutic services or rehabilitation services. (Critical Access Hospitals are certified under separate standards. Psychiatric Hospitals are subject to additional regulations beyond basic hospital conditions of participation.) Inpatient Rehabilitation Facilities and Long Term Care Hospitals are included in the Hospital definition.

Hospitals are also required to conduct planning and preparedness activities that are applicable to an affiliated accrediting organization as well as the New Hampshire Administrative Rules for Hospitals under He-P 802.

Risk Assessment & Planning

Your hospital should develop a plan based on the risk assessment and planning done earlier in the toolkit. The plan should:

    • Be based an include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
    • Include strategies for addressing emergency events identified by the risk assessment.
    • Address patient population, including persons at-risk.
    • Include a process for cooperation and collaboration with local, regional, state, and federal emergency preparedness officials, including documentations of a hospital's efforts to contact those officials.

Policies and Procedures

The policies and procedures included in an emergency preparedness plan need to, at minimum, address the following:

  • Provision of subsistence for staff and patients, including food, water, and medical/pharmaceutical supplies.
  • Alternate sources of energy to maintain emperatures to protect patient health, emergency lighting, fire detection/extinguishing, and sewage/waste disposal.
  • A system to track off-duty staff and sheltered patients in care of the hospital during an emergency
  • Safe evacuation from the hospital, incorporating the needs of evacuees, staff, and primary/secondary means of communication
  • A means to shelter in place for patients, staff and volunteers who remain at the facility
  • A system of documentation that preserves patient information and confidentiality
  • Arrangements with other hospitals and providers to receive patients in the event of limitations or cessation of operations

Communications Planning

The hospital needs to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws. This plan should be reviewed and updated at least annually, and must include the following:

    • Names and contact information for staff, entities providing services, patients' physicians, other hospitals, federal, State, regional and local emergency management staff
    • Primary and alternate means of communicating with hospital staff, federal, state, and local emergency management agencies
    • A method for sharing information and medical documentation for patients with other health care providers
    • A means to release patient information as permitted, under 45 CFR 164.510(b)(1)(ii)

Training and Testing

Hospitals must develop and maintain an emergency preparedness training and testing program based on the risk assessment, policies and procedures, and communications planning above. It must be reviewed and updated at least annually.

Training Program

A training program includes all of the following:

    • Initial training in emergency preparedness policies and procedures to all new and existing staff, consistent with their role
    • Provide emergency preparedness training at least annually
    • Maintain documentation of the training
    • Demonstrate staff knowledge of emergency procedures


The hospital must conduct exercises to test the emergency plan at least annually, by doing all of the following:

    • Participate in a full-scale exercise that is community-based. When a community-based exercise is not accessible, an individual, facility-based exercise. If the hospital experiences an actual natural or man-made emergency that requires activation of the emergency plan, the facility is exempt from engaging in an exercise for 1 year.
    • Conduct an additional exercise, that may include:
      • A second full-scale exercise that is community or facility-based OR
      • A tabletop exercise that includes a group discussion led by the facilitator, using a clinically relevant scenario, designed to challenge the emergency plan

Documentation that analyzes the hospitals response and documentation of all drills, exercises and emergency events and revisions to the plan as needed is required.

Additional Considerations

Emergency Standby and Power Systems

The hospital must implement emergency and standby power systems based on the plans set forth in the above sections. It should include:

  • Emergency Generator Location: Emergency generators must be placed in accordance with Health Care Facility Code.
  • Emergency Generator Inspection and Testing must be completed in accordance with Health Care Facility Code and Life Safety Code.
  • Emergency Generator Fuel: Hospitals that maintain an onsite fuel source to power generators must have a plan for how it will keep systems operational during an emergency, unless it evacuates.

Integrated Health Systems

If the hospital is part of a healthcare system, consisting of multiple separately certified facilities that elects to have a unified and integrated emergency preparedness program, it can participate in the system's coordinated emergency preparedness program.

If participating in the program, the unified and integrated emergency preparedness program must:

    • Demonstrate that each facility within the system participated in the development of the plan
    • Be developed and maintained while taking into account the unique circumstances, patient populations, and services of each facility
    • Include a unified and integrated emergency plan that is based on a documented risk assessment, utilizing an all-hazards approach.