I’ve been on the receiving end of a lot of emergency calls. In 30 years working in public safety dispatch and EMS operations, I’ve talked to people who had no idea what to do, couldn’t tell me where they were, didn’t know who was in charge, and weren’t sure whether to evacuate or shelter in place. Those aren’t failures of courage. They’re failures of preparation.
Most of the time, the facility had a plan. It just wasn’t a plan anyone could actually use.
The Occupational Safety and Health Administration has a regulation that speaks directly to this problem. It’s called 29 CFR 1910.38 — the Emergency Action Plan standard. It’s not complicated. It doesn’t require a binder the size of a phone book. It requires six specific things. And in my experience working with healthcare-adjacent organizations in the Dallas-Fort Worth area, a surprising number of facilities either don’t have all six or have them on paper but haven’t done anything to make them functional.
This post walks through what the regulation actually requires — not a paraphrase, not a summary, but the six elements straight from the standard — and what each one means in practice.
Who does OSHA 29 CFR 1910.38 apply to?
Before the six elements, a quick answer to the question facilities sometimes ask: does this apply to us?
The short answer is almost certainly yes. OSHA’s emergency action plan standard applies to any employer covered by an OSHA standard that requires one — and that covers the overwhelming majority of workplaces, including ambulatory surgery centers, urgent care clinics, behavioral health facilities, dialysis centers, and medical group practices.
There is one narrow exception: employers with ten or fewer employees may communicate the plan orally rather than maintaining it in writing. If you have more than ten employees, the plan must be in writing, kept in the workplace, and available to employees for review. No exceptions to that requirement.
The six required elements
Here is what 29 CFR 1910.38(c) actually says. These are the minimum elements every written emergency action plan must include.
1. Procedures for reporting a fire or other emergency
This sounds obvious. It isn’t, once you get into it.
“Procedures for reporting” means your employees need to know how to initiate an emergency response — not just that they should call 911, but who calls, from where, using what, and what information they need to give. From the dispatch side, I can tell you that “call 911” is not a procedure. A procedure tells someone what to say when the call connects, where to direct the dispatcher when asked for a location, and who notifies internal staff while the external call is being made.
If two people both assume someone else is making the call, no one makes the call. This element exists to eliminate that gap.
2. Procedures for emergency evacuation, including type of evacuation and exit route assignments
This is the element most facilities spend the most time on — and it’s still frequently incomplete.
“Type of evacuation” matters. A full facility evacuation is different from a partial evacuation (clearing one floor or wing). A shelter-in-place is different from both. Your plan needs to address which scenario triggers which response, who makes that call, and how staff know which response is happening right now.
Exit route assignments mean specific routes for specific areas — not a single posted map by the front door. Staff working in the back of a building during an overnight shift need to know their route, not the one on the placard nearest the reception desk.
3. Procedures to be followed by employees who remain to operate critical operations before they evacuate
This element catches a lot of facilities off guard.
Some operations can’t be immediately abandoned. Medical equipment may need to be secured. Patients may be mid-procedure. Controlled substances need to be accounted for. Systems may need to be shut down in a specific order to prevent secondary incidents.
The regulation recognizes this reality and requires that you name the procedures and the employees responsible for them. “Everyone evacuates immediately” isn’t always the right answer — but “someone stays to do X and here’s who and here’s the procedure” is a plan.
4. Procedures to account for all employees after evacuation
This is the element I see skipped most often.
Once your building is evacuated, do you know if everyone got out? Not in general — do you specifically know, based on a documented process, whether every person who was in that building is accounted for?
OSHA requires a procedure. That means designated assembly points, a designated person responsible for conducting the headcount, and a process for reporting to emergency responders. When firefighters arrive on scene, one of the first questions they ask is whether everyone is out. “We think so” is not an answer. Having a name and a count ready is.
5. Procedures to be followed by employees performing rescue or medical duties
Most healthcare-adjacent facilities won’t designate employees for active rescue — that’s what the fire department is for. But medical duties are a different question.
If a staff member has CPR or first aid training and your plan designates them to provide pre-arrival medical assistance, this element requires that those duties be written into the plan and that those employees know what they’re responsible for. It also requires that the rest of your staff know who those people are and what not to do while waiting for them.
6. The name or job title of every employee who may be contacted by employees needing more information about the plan
This is the element that makes the plan functional when things go wrong at 2 a.m. and the person who wrote the plan isn’t there.
Not everyone needs to know every detail of the emergency action plan. But everyone needs to know who to ask. OSHA requires that a named contact — or at least a job title — be designated for this purpose and communicated to all covered employees.
This is also the element that dates fastest. People leave. Titles change. If the name in your plan hasn’t been updated in three years, you may be directing employees to call someone who no longer works there.
Two additional requirements beyond the six elements
The six elements in 1910.38(c) get the most attention, but the regulation includes two other requirements worth noting.
Employee alarm system. Your facility must have and maintain an employee alarm system that uses a distinctive signal for each purpose — evacuation, shelter-in-place, lockdown, and so on. A single alarm tone that means everything means nothing when people need to know immediately what response is required.
Training. OSHA requires that employees be trained to assist in safe and orderly evacuation. It also requires that the plan be reviewed with employees when the plan is first developed, when an employee’s responsibilities change, and when the plan changes. A plan that exists but has never been explained to staff isn’t a plan — it’s a document.
What happens when facilities fall short
OSHA citations for 29 CFR 1910.38 violations are common. The agency classifies violations as serious or willful depending on whether the employer knew about the gap and failed to address it.
As of January 2025, serious violations carry a maximum penalty of $16,550 per violation. Willful or repeated violations can reach $165,514 per violation. Those figures come directly from OSHA’s official penalty schedule and are adjusted annually for inflation.
The financial exposure matters. But it’s secondary to the real risk: a staff member who doesn’t know what to do when something goes wrong, a patient who doesn’t get out, a responder who arrives to a scene with no one able to tell them what’s happening.
A plan that works versus a plan that exists
There’s a difference between having an emergency action plan and having one that your staff can actually execute. The regulation sets the floor — six elements, in writing, available to employees. What happens above that floor is where the real work is.
If your facility has a plan, the right question isn’t “do we have one?” It’s whether the plan covers all six required elements, whether the information in it is current, and whether your staff know it exists and what it says.
If you’re not sure where your plan stands against the six OSHA requirements, that’s a conversation worth having. Adams Operations Group works with healthcare-adjacent organizations in the Dallas-Fort Worth area to develop emergency action plans that meet regulatory requirements and hold up under real conditions. You can schedule a consultation call at adamsopsgroup.com.
Sources: 29 CFR 1910.38, Electronic Code of Federal Regulations (ecfr.gov); OSHA Penalties, U.S. Department of Labor (osha.gov/penalties); OSHA Emergency Action Plans eTool (osha.gov/etools/evacuation-plans-procedures/eap).