How to Create an OSHA-Required Emergency Action Plan in Under an Hour (29 CFR § 1910.38)

OSHA’s Emergency Action Plan (EAP) standard, codified at 29 CFR § 1910.38, requires all employers, including small healthcare practices, to have a written plan that prepares staff for emergencies such as fires, natural disasters, or workplace violence. For small medical clinics, compliance with this rule not only ensures legal protection but also safeguards patients, staff, and community trust during crises. An effective EAP reduces confusion during emergencies, limits liability, and helps practices respond quickly and effectively. Creating a compliant plan can be completed in under an hour when following OSHA’s framework, making it both accessible and essential for small practices.

Small healthcare practices often assume that because they have fewer employees, comprehensive emergency planning is unnecessary or too complex. However, OSHA’s 29 CFR § 1910.38 mandates that every workplace, regardless of size, maintain a clear and accessible Emergency Action Plan. Emergencies in healthcare facilities pose unique challenges, patients may have mobility limitations, medical equipment may require continuous operation, and staff must protect confidential health information. By implementing an EAP, clinics not only comply with OSHA requirements but also create a structured approach that reduces panic, promotes safety, and ensures continuity of care during crises.

Understanding Emergency Action Plans Under 29 CFR § 1910.38

The EAP regulation requires that employers establish and maintain a written plan that includes at least the following elements:

• Procedures for reporting emergencies (fire, chemical spill, severe weather, or workplace violence).

• Evacuation procedures and routes for staff, patients, and visitors.

• Procedures for employees who remain to operate critical operations before evacuation.

• Accounting for all employees after evacuation.

• Rescue and medical duties for designated staff members.

• Contact information for individuals to be notified during emergencies.

Employers with 10 or fewer employees may communicate the plan orally, but documentation is strongly recommended for liability and inspection purposes. Understanding these requirements is vital because failure to maintain an adequate EAP can lead to OSHA citations, penalties, and heightened liability during emergencies.

The OCR’s Authority in Emergency Action Plan Compliance

While OSHA is the primary regulator enforcing 29 CFR § 1910.38, the Department of Health and Human Services Office for Civil Rights (OCR) may also review emergency preparedness in connection with patient rights under HIPAA and nondiscrimination statutes. For example, if patients with disabilities or chronic conditions are not included in evacuation planning, OCR may investigate whether the clinic failed to provide equal access to safe emergency care. Triggers for audits or investigations include:

• Patient complaints regarding safety during emergencies.

• Self-reported incidents after failed emergency responses.

• Reviews during broader OCR or OSHA compliance inspections.

This dual oversight reinforces the importance of having a compliant, inclusive EAP that addresses both workplace safety and patient rights.

Creating an OSHA-compliant EAP in under an hour is achievable with a structured approach.

1. Designate an Emergency Coordinator: Assign a staff member responsible for implementing and updating the EAP. Document the individual’s role and contact information.

2. Outline Emergency Scenarios: Identify the most likely emergencies (e.g., fire, power outage, severe weather) and outline specific responses.

3. Create Evacuation Maps: Mark exits, safe assembly points, and accessible routes for patients with disabilities. Post maps in visible areas.

4. Assign Staff Roles: Identify who will assist patients, manage medical equipment, or handle communications. Document these responsibilities.

5. Set Reporting Procedures: Establish a clear method for reporting emergencies (intercom, alarms, direct communication).

6. Plan for Continuity of Care: Document steps for securing medications, sensitive medical records, and critical equipment.

7. Train and Test: Provide training to all staff and conduct a short drill at least once annually. Record attendance and feedback.

By following these steps, small practices can create and document a compliant EAP within an hour, ensuring both safety and compliance.

A small pediatric clinic failed to create a written Emergency Action Plan (EAP), believing that giving staff oral instructions during orientation was enough to meet compliance expectations. For months, no drills were conducted, and staff were uncertain of their specific roles in an emergency. The lack of preparation became evident when a fire alarm sounded due to an electrical malfunction in a neighboring building. In the confusion, staff members panicked and evacuated patients without coordination. Families rushed out with little guidance, medication refrigerators storing vaccines and critical pediatric treatments were left unsecured, and one child with limited mobility was accidentally left behind for several minutes until a nurse returned to assist. While no one was physically harmed, the incident left parents shaken and concerned about the clinic’s preparedness.

Following a formal patient complaint, OSHA launched an investigation. Inspectors determined that the clinic had violated the Emergency Action Plan requirements under 29 CFR 1910.38, which mandate a written plan outlining procedures for evacuation, alarm systems, and employee responsibilities. Because the clinic had no documented plan, no posted evacuation routes, and no training records, OSHA cited the practice and imposed a $4,500 fine. The citation also included a requirement for a corrective action plan to establish compliance and prevent similar incidents in the future.

In response, the clinic’s leadership developed a comprehensive written EAP tailored to its facility and patient population. Evacuation routes were posted in every hallway, and staff were trained annually to ensure everyone understood their roles in protecting patients, securing medical assets, and responding calmly to alarms. Special attention was given to protocols for assisting children with disabilities or limited mobility. Regular drills were added to the clinic’s operations, and managers were tasked with documenting attendance and outcomes to identify areas needing improvement.

Within a year, the clinic passed a follow-up OSHA inspection with no citations. More importantly, staff reported feeling more confident during drills, and families expressed relief knowing that the clinic had clear, well-practiced emergency procedures. The experience reinforced how a written, well-communicated EAP is not just a regulatory requirement but a vital safeguard for protecting both patients and employees in crisis situations.

• No Written Plan: Assuming verbal communication suffices increases liability and violates OSHA requirements.

• Unposted Evacuation Maps: Staff and patients cannot safely exit without visible routes, leading to fines and safety risks.

• Failure to Assign Roles: Without designated responsibilities, chaos ensues during emergencies.

• Ignoring Patients with Special Needs: Overlooking mobility-impaired patients risks OCR involvement and legal consequences.

• Skipping Drills: Without practice, staff may forget procedures or act inconsistently, reducing emergency effectiveness.

Avoiding these pitfalls ensures compliance, reduces liability, and builds confidence in the clinic’s preparedness.

• Use templates provided by OSHA to streamline EAP creation.

• Develop laminated quick-reference cards for staff with key emergency duties.

• Partner with local fire departments to review evacuation routes and suggest improvements.

• Incorporate patient feedback from drills to improve inclusivity.

• Store digital copies of the EAP in secure, accessible systems for quick reference.

Implementing these practices enhances compliance while ensuring that emergency plans are practical and effective for small healthcare settings.

Building a Culture of Compliance Around Emergency Action Plans

Sustainable compliance requires integrating emergency planning into daily operations. Small practices should:

• Include EAP responsibilities in job descriptions.

• Provide regular training and refresher courses during staff meetings.

• Encourage staff to report potential hazards or gaps in emergency preparedness.

• Recognize staff participation in drills to promote engagement.

• Emphasize leadership accountability in maintaining and updating the EAP.

Embedding emergency preparedness into the clinic’s culture ensures long-term compliance and readiness.

OSHA’s Emergency Action Plan standard (29 CFR § 1910.38) is a vital requirement that protects staff, patients, and healthcare operations. Small practices can achieve compliance in under an hour by following structured steps, documenting responsibilities, and training staff.

Advisers: Affordable compliance software can simplify documentation, track training, and schedule drills. Free government resources from OSHA, HHS, and OCR offer practical templates, hazard assessment tools, and patient safety guidance. Leveraging these tools helps small practices maintain ongoing compliance without significant financial strain.

• 29 CFR 1910.38, Emergency Action Plans (eCFR)

• HHS Office for Civil Rights, Emergency Preparedness Guidance

• Federal Register, OSHA Emergency Preparedness Updates