Home health & hospice · Wildfire planning

When the Evacuation Order Comes: Wildfire Planning for Home Health and Hospice

By Dr. Arzoo Salami, physician & founder, SurgeReady · July 31, 2026 · 8 min read

The fire is the part everyone handles. Staff show up, patients get moved, people are heroic about it. What breaks is the 72 hours after the order, when your patients are spread across hotels, relatives' spare rooms, and a shelter two counties over, several of them without the equipment they depend on, and your agency is still responsible for their care. That stretch is the part most emergency plans do not describe, and it is the part CMS asks about in language that surprises people when they finally read it.

What Altadena Showed

In January 2025, Direct Relief mapped healthcare facilities in the path of the Los Angeles fires. In the Eaton Fire area, at least four were confirmed or likely destroyed. One of them was Alta Loma Hospice. Not a hospice patient's home, the hospice.

A fifth finding on that map is the one I keep coming back to. Eaton Canyon Dialysis Center did not appear damaged, but it sat close enough to the destruction that its operating status was, in Direct Relief's words, highly questionable. The building was standing. Whether anyone could get to it, staff it, or run it was a separate question entirely.

That gap between a facility existing and a service being available is where continuity plans quietly fail. If your plan for a patient on home dialysis says "patient receives treatment at their center," the plan has not answered the question. It has restated it.

None of this is behind us. As I write this, Oregon has more than 1.5 million acres burning, with thousands of residents under Go Now evacuation orders and a special care home in British Columbia relocating 53 residents while still only at the alert stage.

The Two Sentences Most Agencies Have Never Read

Home health and hospice sit under different sections of the CMS Emergency Preparedness Rule, 42 CFR §484.102 and 42 CFR §418.113, but on evacuation the two are nearly word for word the same. Both contain a pair of requirements that most administrators have never been walked through, because they read the rule as a document to produce rather than a set of duties to perform.

The first is a duty to report patients who need to get out. Home health at §484.102(b)(2), hospice at §418.113(b)(2): you must have procedures to inform State and local emergency preparedness officials about patients in need of evacuation from their residences, based on the patient's medical and psychiatric condition and home environment. Not a plan to evacuate them yourself. A procedure to tell the people with the vehicles and the authority who and where they are.

The second is a duty to report the patients you lose track of. Home health at §484.102(b)(3), hospice at §418.113(b)(1): after an interruption in services, you follow up with on-duty staff and patients to determine what is needed, and you must inform State and local officials of any on-duty staff or patients that you are unable to contact.

Read that again, because it inverts how most agencies think about the worst moment of a response. "We could not reach fourteen patients" feels like the end of the story, the point where an agency has run out of options. In the regulation it is not the end of anything. It is a trigger. Fourteen unreachable patients is fourteen notifications you owe someone, by name, that day.

I have never met an administrator who objected to that duty once they saw it. I have met plenty who had no idea whose phone number it was.

Four Things That Break

1. The route fails before the plan does

On November 8, 2018, staff at Adventist Health Feather River in Paradise evacuated at least 45 patients as the Camp Fire burned onto the hospital campus. One ambulance carrying evacuees traveled roughly half a mile before it began to melt. Nurses, EMS crews and patients ended up sheltering in an abandoned house until they could be moved.

Hold the details of that for a second. This was a hospital, with an emergency management function, an incident command structure, and EMS physically present, and the evacuation route still closed around them.

One of your nurses, alone in a Corolla, driving toward a patient's house, has worse odds than that.

Almost every home health and hospice plan I read describes how staff will reach patients during an emergency. Very few name the point at which the agency stops sending people. That threshold matters more than the reaching plan does, because if it is not written down it still gets decided, at 2am, by one nurse in a car who does not want to be the person who abandoned a patient. That is an unfair thing to hand to an individual clinician, and it is a decision an agency can make in advance, calmly, in writing.

Name the trigger, and be specific: which evacuation zone designations, which road closure sources you will treat as authoritative, what air quality reading, what time of night. Name who makes the call and who makes it when that person is unreachable. Then name what replaces the visit, because "no visit" is not a plan and a phone call is.

2. The power goes out before the fire arrives

For a large share of your caseload the emergency does not start when the fire does. It starts when a utility opens a breaker, or when a transformer goes, and that can happen days early and miles away.

The equipment that stops working is not exotic:

• Oxygen concentrators
• Ventilators and BiPAP machines
• At-home dialysis machines
• IV infusion pumps and enteral feeding pumps
• Suction pumps
• Electric beds, power wheelchairs and scooters
• Refrigerated medication, including insulin

Ask what the actual fallback is for each patient who depends on one of these, and the honest answer is usually that they will call 911 and come to an emergency department. Mine, or one like it. That is a real plan and sometimes the right one, but it should be a choice your agency made deliberately, not the default that appears when nobody planned anything. It also means every one of those patients arrives in the same few hours as everyone else's, at a hospital that is managing its own surge.

3. Your staff are evacuees too

Reporting from Los Angeles during the January 2025 fires described the thing that actually degrades coverage: clinicians losing their own homes, evacuating their own neighborhoods, and being unable to work not from unwillingness but because they were inside the disaster with everyone else. Offices closed. Appointments were canceled. Staffing got hard for reasons no schedule anticipated.

CMS asks you to plan for this. Home health at §484.102(b)(5), hospice at §418.113(b)(4), both require emergency staffing strategies, including the use of volunteers and the integration of State or Federally designated health care professionals to address surge needs.

A staffing plan that assumes your roster is available is a staffing plan for a disaster that happens somewhere else. Build yours around the assumption that some fixed share of your staff, in the same service area as your patients, are personally displaced on day one.

4. "A few days" is the wrong planning horizon

One family covered in reporting on the Eaton Fire evacuated with supplies for a few days. Nine months later they still had not moved back, because of the chemical contamination left inside a house that never burned.

Fire does not have to destroy your patient's home to make it uninhabitable, and smoke and contamination displacement runs on a scale of months.

So your continuity plan needs a version that goes past 72 hours. Where does this patient receive care when their home is standing but unlivable, they are staying with a daughter two counties away, and that address is outside your service area? Who holds the relationship, who transfers the record, and at what point do you discharge and hand off rather than pretend you are still covering them? Answer it in advance and it is a workflow. Answer it in week three of a displacement and it is a scramble, and it is also where continuity of care genuinely gets dropped.

A Free Federal Tool Most Small Agencies Do Not Use

The HHS emPOWER Map is a public, interactive tool from ASPR and CMS. It shows, down to the ZIP code, how many Medicare beneficiaries in an area rely on electricity-dependent durable medical equipment or essential services like home oxygen. The categories behind it are specific: ventilators, BiPAP, enteral feeding machines, IV infusion pumps, suction pumps, at-home dialysis, electric wheelchairs and scooters, electric beds, oxygen concentrators, and implanted cardiac devices.

It is free, it requires no login, and almost nobody in small home health or hospice uses it. Two ways it earns its place in your program:

It makes your risk assessment specific. The most common weakness I see in an all-hazards risk assessment is that it could describe any agency in any state. Being able to write that a given number of electricity-dependent Medicare beneficiaries live in the ZIP codes you serve turns a generic hazard list into a document about your service area.

It gives you a reason to introduce yourself to emergency management. The regulation requires you to notify local officials about patients needing evacuation and patients you cannot reach. Those notifications go much better when they are not the first time that office has heard your agency's name. Walking in with local data is a better opening than walking in during a fire.

One caveat so you use it correctly: emPOWER counts Medicare beneficiaries in a geography, not your census. It sharpens your risk assessment. It does not substitute for knowing your own patients.

What to Do This Week

None of this requires a consultant or a budget. Work through it in order:

1. 1Pull your patient list and flag every patient who depends on electricity for equipment or refrigerated medication. That flagged list, not the plan binder, is what you will actually work from.
2. 2For each flagged patient, write down where they go and who moves the equipment. If the record says "family will assist," replace it with a name and a phone number.
3. 3Write your threshold for stopping in-person visits: the trigger, who decides, who decides when that person is unreachable, and what replaces the visit.
4. 4Find out who at your county or city emergency management agency receives the notifications §484.102(b)(2) and (b)(3), or §418.113(b)(1) and (b)(2), require you to make. Get a name, a direct number, and an after-hours path. Call it once now, while nothing is burning.
5. 5Call every number in your communication plan, including patient emergency contacts. You will find the wrong ones either this week or during a fire.
6. 6Check what duration your plan assumes. If it ends at 72 hours, write what happens at 30 days and at 90.
7. 7Look up your service ZIP codes on the HHS emPOWER Map and put the number into your risk assessment.

Where to Start

If your risk assessment is the piece you are least confident about, start there, because everything else in the program is supposed to follow from it. I built free All-Hazards Risk Assessment Worksheets for home health and for hospice, written for care delivered in patients' homes rather than adapted from a hospital's plan.

If you have not read the survey-prep side of this yet, it pairs with what CMS requires of a home health agency and how surveyors actually check it.

This article is general information, not legal or regulatory advice. Verify current federal requirements at 42 CFR §484.102 and §418.113, and check your state's additional requirements, which in wildfire states are often stricter than the federal floor.