CMS SOM App. E, Tag I-171

The organization has a written plan in operation, with procedures to be followed in

the event of fire, explosion, or other disaster. The plan is developed and maintained

with the assistance of qualified fire, safety, and other appropriate experts, and

includes:

(1) Transfer of casualties and records;

(2) The location and use of alarm systems and signals;

(3) Methods of containing fire;

(4) Notification of appropriate persons; and

(5) Evacuation routes and procedures.

Interpretive Guidelines §485.727(a)

A – General

The disaster plan must be developed with the assistance of fire, safety, and other

appropriate experts. Ensure that the written disaster plan (which includes each of the five

specified items under this standard) is operational, contains procedures to be followed,

evacuation routes, and assignment of staff responsibilities in the event of a disaster.

Verify that the description of the location of the alarms systems is accurate.

One component of the disaster plan is the fire protection plan. A written copy of the fire

protection plan should be in effect and readily available to all personnel. The plan is

designed

for the protection of all facility occupants and their evacuation in the event of fire

and should provide for, at a minimum: the use of alarms, notification of the fire

department, response to alarms, isolation of fire, evacuation, and extinguishment of fire.

All employees should be periodically instructed regarding their duties under the plan.

B – Major Sources of Information

• Organization’s disaster plan;

• Organization policies and procedures; and

• Surveyor observations.