Policy required document Workplace
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.
Obligation ledger
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(b)(1) | Extinguishers are provided but employees are expected to evacuate immediately | An EAP and fire prevention plan in place of extinguisher training. This is the trigger for most offices and retail. Legally required. | Mandatory |
| CMS emergency preparedness conditions of participation 42 CFR 484.102 (home health), 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 health and safety standards CARF standards manual, Section 1.H | You seek CARF accreditation | Written emergency procedures, unannounced drills on each shift at each location, and documented analysis of drill performance. Accreditor expectation, contractual once you apply. | Implied |
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
What changed
Change log.
Frameworks
Where this document is required.
Who looks at it
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 |
| ISNetworld/Avetta | Platform reviewers (ISN's RAVS team, Avetta's review specialists) grading documents against client and regulatory checklists; hiring clients may additionally audit contractors in the field. No independent certification or accreditation exists |
| 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 |
Who helps write it
Consultants.
Firms that name these standards in their own material.
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Where it lives
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From the publisher
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Questions
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 two exercises a year for most provider types 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.
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