CMS SOM App. K, Tag I-593

The facility must have written policies and procedures that specifically define the

handling of patients, personnel, records, and the public during disasters. All personnel

associated with the facility must be knowledgeable with respect to these procedures, be

trained in their application, and be assigned specific responsibilities.

A - General

A well -developed disaster plan is to be documented and posted in areas accessible for

continuing personnel review and where the public can see it.

B - Major Sources of Information

• Disaster plan; and

• Documentation as to ongoing training sessions and dates of disaster drills

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I-594, I-595, I-596, I-597, I-598

(Rev. 16, Issued: 01-10-06; Effective/Implementation Date: 11-21-05)

§485.64(a) Standard: Disaster Plan

The facility’s written disaster plan must be developed and maintained with assistance of

qualified fire, safety, and other appropriate experts. The plan must include:

(1) Procedures for prompt transfer of casualties and records;

(2) Procedures for notifying community emergency personnel (for example, fire

department, ambulance, etc.);

(3) Instructions regarding the location and use of alarm systems and signals and

fire fighting equipment; and

(4) Specification of evacuation routes and procedures for leaving the facility.

The disaster plan should document the assignment of responsibilities to CORF personnel

providing services to the CORF, evacuation routes, and procedures for the transfer of records

and casualties. In addition, the plan should include procedures for notifying community

emergency personnel, procedures for leaving the facility and instructions regarding the

location and use of alarms and fire fighting equipment.

Review the disaster plan to determine if the plan documents all of the above procedures and

instructions. If CORF employees are working at off-site locations, it is incumbent upon the

CORF to ensure those employees have been trained and are knowledgeable regarding disaster

plans, evacuation routes for those locations, etc. Surveyors should interview staff to

determine whether the CORF has provided training in the off-site locations.

I-599, I-600 - I-601

(Rev. 16, Issued: 01-10-06; Effective/Implementation Date: 11-21-05)

§485.64(b) Standard: Drills and Staff Training

(1) The facility must provide ongoing training and drills for all personnel associated

with the facility in all aspects of disaster preparedness; and

(2) All new personnel must be oriented and assigned specific responsibilities

regarding the facility’s disaster plan within 2 weeks of their first workday.

Every CORF must provide ongoing training and drills for all personnel associated with

the facility in all aspects of disaster preparedness. Larger, more complex CORFs would

most likely provide ongoing training more frequently than smaller CORFs. All new

employees must be oriented and assigned specific responsibilities as part of the disaster

plan within 2 weeks of their first workday. This includes all employees who provide

services to the CORF under an arrangement. The date of training and names of those

persons taking part are to be documented.

Review the CORF’s written Disaster Plan. Verify that all personnel have been instructed

and trained in their responsibilities and that all new personnel are properly trained within

2 weeks of their first workday. Interview the staff to ensure that they are familiar with the

plan as well as being familiar with their role in the plan.