Date of Award

December 2022

Degree Type


Degree Name

Doctor of Philosophy


Health Care Informatics

First Advisor

Priya Nambisan

Committee Members

Edmund Duthie, Colleen Galambos, Bo Zhang, Jennifer Kibicho


Disaster, Emergency, Risk


The COVID-19 pandemic exposed weaknesses in the U.S. public health infrastructure and demonstrated that various groups may be disproportionately affected by a public health emergency. Specifically, the pandemic highlighted the vulnerability of older adults, particularly those living in long-term care facilities. Although nursing homes house less than 1% of the nation's population, they account for 40% of COVID-19 deaths. To encourage comprehensive and collaborative emergency preparedness planning in nursing homes, which face unique challenges in safeguarding residents’ health, the Centers for Medicare and Medicaid Services (CMS) established regulatory standards for emergency preparedness programs (E-Tags) that must be achieved by all certified long-term care facilities. This study explored the relationship between compliance with these standards and incidence of COVID-19 morbidity and mortality within nursing homes after controlling for facility characteristics, as well as how prior experiences with federally declared disasters affected compliance. This quantitative, correlational study included 14,754 certified nursing homes and utilized multiple secondary datasets obtained from CMS (Fire Safety Deficiencies, Nursing Home COVID-19 Public File, and Provider Information) and the Federal Emergency Management Agency (FEMA). Incidence proportions of COVID-19 morbidity and mortality among residents were calculated and two multiple linear regression models were analyzed to evaluate whether the number of deficiencies in a nursing home was associated with these incidence proportions after controlling for region, facility size, and ownership type. A Pearson chi square analysis was conducted to assess the correlation between the number of deficiencies cited and previous federally declared disasters. This study found that the number of citations received by nursing homes for E-Tag deficiencies was significantly and positively associated with COVID-19 morbidity and mortality among residents, although the effect size was small. Region, facility size, and ownership type were significant predictors of morbidity and mortality. Training and Testing and Emergency Plan elements were shown to be the most important predictors of morbidity and mortality, reflecting the need for an all-hazards approach to emergency planning within nursing homes and for inclusion of these facilities in community-level preparedness efforts by local and state emergency management and public health agencies. Previous experience with federally declared disasters was not associated with compliance with emergency preparedness standards.

Available for download on Monday, December 23, 2024