Hospital Legal Preparedness: Relevant Resources

Hospitals are required by laws, regulations, and accreditation requirements to plan for disasters. Proposed regulations from the Centers for Medicare & Medicaid Services may have an effect on these requirements. Because law may impact all stages of emergency preparedness and response, and is a required consideration under the Joint Commission standards Leadership (LD) 04.01.01 & 04.01.07[PDF 38.3KB], legal issues should be incorporated into hospital emergency planning. The following list, compiled by CDC’s Public Health Law Program, can help hospitals incorporate law into emergency preparedness.

The list features resources developed by the following agencies and organizations:

CDC: Public Health Law Program (PHLP)
HHS: Assistant Secretary for Preparedness and Response (ASPR)
HHS: Office of Civil Rights (OCR)
HHS: Office of the National Coordinator for Health Information Technology (ONC)
Centers for Medicare and Medicaid Services (CMS)
Association of State and Territorial Health Officials (ASTHO)
National Association of County and City Health Officials (NACCHO)
Network for Public Health Law (Network)
Johns Hopkins Preparedness and Emergency Response Research Center (Johns Hopkins PERRC)
Johns Hopkins Center for Law and the Public’s Health, Preparedness and Catastrophic Event Response Consortium (PACER)
American Health Lawyers Association (AHLA)
Metro Health & Medical Preparedness Coalition
Equal Employment Opportunity Commission (EEOC)

This list will be updated as new resources become available. Contact the Public Health Law Program at PHLawProgram@cdc.gov with suggestions for additional resources.

Selected Federal Legal Authorities Pertinent to Public Health Emergencies [PDF 282KB]
PHLP list of federal laws that address preparing for and responding to a range of natural and man-made disasters and emergencies

Legal Preparedness for Public Health Emergencies: A Model for Minimum Competencies for Mid-Tier Public Health Professionals [PDF 362KB]
PHLP’s model competencies to advance the inclusion of law-based content in all public health emergency training, resources, and tools

Emergency Preparedness Response & Recovery Checklist: Beyond the Emergency Management Plan
Checklist for healthcare facilities to prepare for or address an emergency (copyright 2014, American Health Lawyers Association)

Lessons Learned from the Gulf Coast Hurricanes
Document on lessons learned by healthcare providers during the 2005 Gulf Coast hurricanes (copyright 2014, American Health Lawyers Association)

Community Pan-Flu Preparedness: A Checklist of Key Legal Issues for Healthcare Providers
Tool to help healthcare providers, public health agencies, and government officials take concrete steps to prepare for and respond to a flu pandemic (copyright 2014, American Health Lawyers Association)

A Patient’s Guide to Emergency Preparedness
Guide for patients, hospital executives, administrators, and emergency physicians and nurses to ensure individuals with chronic or terminal conditions receive appropriate attention during community- or nation-wide emergencies (copyright 2014, American Health Lawyers Association)

Emergency Preparedness Toolkit
Toolkit providing policies on emergency preparedness forms, procedures, links, articles, sample contract language, and legal summary memoranda to help healthcare attorneys, administrators, and providers prepare for and respond to issues that arise during an emergency (copyright 2014, American Health Lawyers Association)

Emergency Authority and Immunity Toolkit
ASTHO toolkit that outlines key concepts of how federal and state emergency declarations initiate various response authorities and liability protections

Public Health and Information Sharing Toolkit
ASTHO toolkit that addresses key concepts regarding public health agencies’ authority to collect, use, and share information to prepare for and respond to a public health emergency

Health Information Disclosures for Emergency Preparedness—A Decision Tool
OCR decision tool for information disclosure decision making during an emergency

FAQ: Is the HIPAA Privacy Rule suspended during a national or public health emergency?
OCR list of frequently asked questions on the Health Insurance Portability and Accountability Act (HIPAA) privacy rule during emergencies

Emergency Preparedness Planning and Response Guidance
OCR guidance on HIPAA privacy during emergencies

Bulletin: HIPAA Privacy and Disclosures in Emergency Situations [PDF 31KB]
OCR bulletin released during Hurricane Katrina on rules about patient information for persons affected by the hurricane

Hurricane Katrina Bulletin 2: Compliance Guidance and Enforcement Statement [PDF 121KB]
OCR bulletin released during Hurricane Katrina on patient information for persons affected by the hurricane

Letter to Health Care Providers After Newtown, CT and Aurora, CO Mass Shootings [PDF 45KB]
OCR letter to healthcare providers on health information privacy as it relates to mass shootings

HIPAA Privacy Rule and Sharing Information Related to Mental Health
OCR guidance on HIPAA and Mental Health

Privacy & Security Training Games
ONC training modules on health information contingency planning in the context of disasters

Legal Authorities: 1135 Waivers
ASPR guidance on 1135 waivers of Children’s Health Insurance Program (CHIP), Centers for Medicare & Medicaid Services (CMS), and HIPAA requirements

Requesting an 1135 Waiver [PDF 65KB]
CMS guidance on requesting an 1135 waiver

Emergency-Related Policies and Procedures That May Be Implemented Without § 1135 Waivers [PDF 893KB]
CMS document answering frequently asked questions on emergency response-related policies and procedures that may be implemented without 1135 waivers, specifically addressing recent disasters and targeted for certain types of healthcare providers

Emergency and Disaster-Related Policies and Procedures That May Be Implemented Only With a § 1135 Waiver [PDF 580KB]
CMS document answering frequently asked questions on emergency response-related policies and procedures which may only be implemented with an 1135 waiver

Provider Survey and Certification: Frequently Asked Questions on Declared Public Health Emergencies—All Hazards Health Standards and Quality Issues [PDF 236KB]
CMS list of frequently asked questions on the effect of emergencies on healthcare providers, including hospitals

Waiver or Modification of Requirements under Section 1135 of the Social Security Act [PDF 320KB]
Official text of HHS Secretary Sibelius’s 1135 waiver during the H1N1 pandemic

NY 1135 Waiver—October 31, 2012 [PDF 238KB]
Official text of HHS Secretary Sibelius’s 1135 waiver for New York during Hurricane Sandy

NJ 1135 Waiver—November 1, 2012 [PDF 1.4MB]
Official text of HHS Secretary Sibelius’s 1135 waiver for New Jersey during Hurricane Sandy

Hurricane Sandy 1135 Waiver Summary [PDF 83KB]
CMS summary of the 1135 waivers issued during Hurricane Sandy

Emergency Use Authorizations (EUA)
FDA website providing background information on EUAs and a list of current EUAs issued by the FDA Commissioner

Medical Countermeasures (MCMs) Legal, Regulatory, and Policy Framework
FDA list of resources related to the use of MCMs in response to a chemical, biological, radiological, nuclear, or infectious disease emergency

Scope of Practice Toolkit
ASTHO toolkit that reviews key issues regarding the scope of practice of various healthcare professionals and expanding that scope during emergencies

Emergency Authority and Immunity Toolkit
ASTHO toolkit that outlines key concepts of how federal and state emergency declarations initiate various response authorities and liability protections

Emergency Volunteer Toolkit
ASTHO toolkit that addresses key concepts regarding emergency response volunteers, including types of volunteers, federal and state laws governing or affecting volunteers, and volunteer registration

Quick Reference: Reviewing Emergency Volunteer Liability and Protections
Network for Public Health Law quick reference that outlines federal and state laws tied to each individual type of emergency volunteer

Medical Licensure and Other Emergency Legal Preparedness Issues for the American Red Cross [PDF 180KB]
Network for Public Health Law resource listing questions and answers regarding the legal issues presented by American Red Cross physicians providing services during disasters

Selected Model Memoranda of Understanding
PHLP list of model MOUs to enhance coordination of preparedness across sectors

Model MOU Between Hospitals during Declared Emergencies [PDF 140KB]
Preparedness and Catastrophic Event Response consortium model memorandum of understanding for use by hospitals during declared emergencies

Metropolitan Area Hospital Compact [PDF 31KB]
Agreement by the Metro Health & Medical Preparedness Coalition to serve as an example compact for metropolitan or regional disaster readiness agreements

Model Hospital Mutual Aid Memorandum of Understanding [PDF 46KB]
AHA model hospital MOU adapted from a mutual aid agreement by the DC Hospital Association

H1N1 Fact Sheet—Hospital Alternative Care Sites during H1N1 Public Health Emergency [PDF 199KB]
CMS guidance issued during the H1N1 pandemic describing how CMS payments and reimbursements operate when alternate care sites are in use

Social Distancing Law Assessment Template
Template for assessing legal authorities, a hypothetical scenario, instructions for conducting a legal consultation meeting on social distancing policies, and examples of completed documents

Ebola and the Law: Legal Preparedness for Physicians and Hospitals PDF 343KB]
PHLP issue brief describing select points of interest—including case law, statutes, and information about CDC guidance—highlighted during a presentation entitled “Ebola and Public Health Law” delivered by Gregory Sunshine and Montrece Ransom at the 2015 American Health Lawyers Association Physicians and Hospitals Law Institute

Interim Table of State Ebola Screening and Monitoring Policies for Asymptomatic Individuals
PHLP table and map of each state and territorial Ebola screening, movement, and monitoring policy as expressed in publicly available orders, protocol documentation, and press releases

Public Health Preparedness: Examination of Legal Language Authorizing Responses to Radiological Incidents [PDF 669KB]
PHLP assessment of state and local laws that authorize restriction of movement and decontamination of people during a radiological event

Identifying Vulnerable Older Adults and Legal Options for Increasing Their Protection During All-Hazards Emergencies: A Cross-Sector Guide for States and Communities
PHLP guidance on legal preparedness issues related to older adults, covering topics such as developing plans, partnering and collaboration, using data for action, building registries, using law-based solutions, sheltering, and caregiver preparedness

Pandemic Preparedness in the Workplace and the Americans with Disabilities Act
EEOC guidance for employers on the implications of the Americans with Disabilities Act for pandemic planning

First Responders, Mental Health Services, and the Law [PDF 64KB]
Johns Hopkins PERRC resource on how the law can facilitate the provision of mental health services to first responders during and shortly after emergencies

Frequently Asked Questions about Legal Preparedness for Health Care Providers and Administrators, Public Health Officials, Emergency Planners, and Others Regarding Mental and Behavioral Health [PDF 157KB]
Johns Hopkins PERRC resource addressing frequently asked questions on legal issues that arise during and after emergencies relative to mental and behavioral health

Prescribing Authority During Declared Emergencies for Mental and Behavioral Health Care Providers [PDF 104KB]
Johns Hopkins PERRC document identifying key legal issues that may arise during and after emergencies relative to prescribing authority for mental healthcare practitioners

Sample Legal Guidance Letter—Liability for Mental Health Care Providers [PDF 95KB]
Johns Hopkins PERRC sample legal guidance letter that applicable legal counsel can tailor according to their circumstances and jurisdiction to advise clients on liability risks and protections for mental healthcare providers during an emergency

Mental Health Legal Preparedness and Crisis Standard of Care [PDF 96KB]
Johns Hopkins PERRC resource on the recent Institute of Medicine Crisis Standard of Care Report and its recommendations for mental health care in emergencies

Public Health Emergency Law 3.0
PHLP training to help public health practitioners and emergency management professionals improve their understanding of the role of law in public health emergency response

Public Health and the Law: An Emergency Preparedness Training Kit
NACCHO training kit to enhance local public health professionals’ and their legal counsel’s knowledge of the legal authorities and issues that shape their ability to prepare for, respond to, and recover from public health emergencies

IS-200.HCA: Applying ICS to Healthcare Organizations
FEMA training for healthcare organizations on how to use the Incident Command System when responding to emergencies

Planning Resources by Setting: Hospitals and Healthcare Systems
CDC list of resources to help healthcare providers, staff, hospital administrators, and chief executive officers plan for and respond to public health emergencies

Disclaimer: Information available on this website that was not developed by the Centers for Disease Control and Prevention (CDC) does not represent CDC policy, position, or endorsement of that information or of its sources. The information contained on this website is not legal advice; if you have questions about a specific law or its application, consult your legal counsel.