Emergency Services and Response


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Due to our recent experience with the COVID-19 pandemic, we are considering using our efforts to manage the virus in our facilities as compliance with the mass disaster drill requirement. Would this meet the intent of the standard? All our shifts and staff have been affected and play a major role in our daily efforts.

Great question! The answer is yes. This is a perfect example of how facilities can use a real-life event to meet the mass disaster requirement. Standard D-07 Emergency Services and Response Plan addresses planning for disruptions in service during emergencies and requires that mass disaster drills be conducted so that each shift, including satellite facilities, has participated in a drill over a three-year period. The drills must then be critiqued and the results shared with all health staff. NCCHC asks that staff members who are not present during a drill later review and initial the written critiques.  

— From CorrectCare Volume 34, Issue 3, Summer 2020


Standard D-07 Emergency Services and Response Plan for jails and prisons requires that mass disaster drills are conducted so that each shift has participated over a three-year period. This is what our jail has been doing. However, a new jail has been constructed, and the old one no longer houses inmates. We rehearsed the new disaster plan in the old building about four months before moving into the new one. Can we count that rehearsal as a drill or must we have another drill in the new building?

The intent of this standard is to ensure that all staff are prepared to effectively respond during emergencies. Some considerations in a good mass disaster plan can be verified only by rehearsing the plan within the specific environment. For example: Does everyone know where the emergency equipment and supplies are? Is the equipment operable? Are the needed supplies available? Where will triage be performed? Where will injured people be taken? If not on duty at the time of the disaster, which members of the health staff will be called? Will security measures, such as automatic doors, impede transport of casualties? The layout of the building and the security measures may be different, necessitating new procedures that differ from what was envisioned before the facility opened.

Although classroom exercises and staff discussions can be useful, they are not sufficient to meet this standard. Therefore, another drill should be held in the new facility.

— From CorrectCare Volume 33, Issue 1, Winter 2019


Our facility has fire drills about four times a year. Do these count as disaster drills under D-07 Emergency Services and Response Plan?

If these are routine fire drills for the whole facility, probably not. This standard focuses on the health aspects of the disaster plan. Practicing emergency response plans enables health staff to better respond to disasters when they occur.

While health staff need to participate in basic fire drills to ensure that they know how and where to evacuate themselves and their patients, they also need to practice their own plans for a disaster. Suppose there was a fire in an inmate housing area or the medical area and several inmates were injured and/or the medical area was destroyed. You might be interested in learning whether:

  • Correctional staff followed procedure in notifying health staff of the disaster and vice versa
  • Their responses were timely
  • Patients were triaged appropriately
  • Emergency/disaster kits were equipped as needed
  • Emergency equipment functioned adequately
  • Staff knew how to use the equipment

If you practice your plan and then critique it, you can correct any deficiencies and lessen the chances of inappropriate actions in the event of a real disaster.

— From CorrectCare Volume 32, Issue 2, Spring 2018


We have a jail system that consists of a main jail and a satellite about three miles away. This satellite is primarily used for intake and receiving. The health staff at the satellite does mass disaster drills at the main site, and process and outcome studies are also done at the main site. Both sites do man-down drills. Is this sufficient or does the satellite need to do mass disaster drills and CQI studies, as well?

The two standards in question are A-06 Continuous Quality Improvement Program and A-07 Emergency Response Plan. The intent of the CQI standard is that a facility uses a structured process to find areas in the health care delivery system that need improvement and that when such areas are found, staff develop and implement strategies for improvement. This includes doing the same for the satellite facilities. The number of process and outcome studies depends on the ADP of the satellite facility.

The intent of the Emergency Response Plan standard is that a facility protects the health, safety and welfare of inmates, staff and visitors during emergencies. Satellite facilities must be included in this process, as well. One mass disaster drill must be conducted annually in the satellite facility so that over a three-year period, each shift has participated. If full-time health staff are not assigned to a particular shift, that shift is exempt from drills. If there are no full-time health staff, drills are not required. The number of mass disaster drills that must be conducted in the satellite facility depends on the staffing plan.
— From CorrectCare Volume 27, Issue 3, Summer 2013


Recently, we had a fire in our facility and had to implement our emergency response plan and evacuate a housing unit. Can we use the critique of this incident toward meeting the A-07 Emergency Response Plan standard, even though there were no casualties?

Yes. Actual emergencies, whether or not injuries were involved, can certainly be critiqued and shared with staff to meet the intent of this standard. (See the Discussion section in the standard.)
— From CorrectCare Volume 23, Issue 2, Spring 2009