CMS SOM App. Z, Tag E-0022

§482.15(b)(4), §483.73(b)(4), §483.475(b)(4), §485.68(b)(2), §485.625(b)(4),

§485.727(b)(2), §485.920(b)(3), §491.12(b)(2), §494.62(b)(3).

(b) Policies and procedures. The [facilities] must develop and implement emergency

preparedness policies and procedures, based on the emergency plan set forth in

paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and

the communication plan at paragraph (c) of this section. The policies and

procedures must be reviewed and updated at least every 2 years [annually for LTC

facilities]. At a minimum, the policies and procedures must address the following:]

[(4) or (2),(3),(5),(6)] A means to shelter in place for patients, staff, and volunteers

who remain in the [facility].

*[For Inpatient Hospices at §418.113(b):] Policies and procedures.

(6) The following are additional requirements for hospice-operated inpatient care

facilities only. The policies and procedures must address the following:

(i) A means to shelter in place for patients, hospice employees who remain in

the hospice.

Interpretive Guidelines applies to: §403.748(b)(4), §416.54(b)(3), §418.113(b)(6)(i),

§441.184(b)(4), §460.84(b)(5), §482.15(b)(4), §483.73(b)(4),

§483.475(b)(4),

§485.68(b)(2), §485.625(b)(4), §485.727(b)(2), §485.920(b)(3), §491.12(b)(2),

§494.62(b)(3).

NOTE: This does not apply to Transplant Programs, HHAs or OPOs.

Emergency plans must include a means for sheltering all patients, staff, and volunteers

who remain in the facility in the event that an evacuation cannot be executed. In certain

disaster situations (such as tornadoes) , sheltering in place may be more appropriate as

opposed to evacuation and would require a facility to have a means to shelter in place for

such emergencies. Therefore, facilities are required to have policies and procedures for

sheltering in place which align with the facility’s risk assessment.

Facilities are expected to include in their policies and procedures the criteria for

determining which patients and staff would be sheltered in place. When developing

policies and procedures for sheltering in place, facilities should consider the ability of

their building(s) to survive a disaster and what proactive steps they could take prior to an

emergency to facilitate sheltering in place or transferring of patients to alternate settings

if their facilities were affected by the emergency. For example, if it is dangerous to

evacuate or the emergency affects available sites for transfer or discharge, then the

patients would remain in the facility until it was safe to effectuate transfers or discharges.

The plan should take into account the appropriate facilities in the community to which

patients could be transferred in the event of an emergency. Facilities must determine

their policies based on the type of emergency and the types of patients, staff, volunteers

and visitors that may be present during an emergency. Based on its emergency plan, a

facility could decide to have various approaches to sheltering some or all of its patients

and staff.

Survey Procedures

• Verify the emergency plan includes policies and procedures for how it will provide a

means to shelter in place for patients, staff and volunteers who remain in a facility.

• Review the policies and procedures for sheltering in place and evaluate if they

aligned with the facility’s emergency plan and risk assessment.