CMS SOM App. Z, Tag E-0029

§483.475(c), §484.102(c), §485.68(c), §485.625(c), §485.727(c), §485.920(c),

§486.360(c), §491.12(c), §494.62(c).

(c) The [facility] must develop and maintain an emergency preparedness

communication plan that complies with Federal, State and local laws and must be

reviewed and updated at least every 2 years [annually for LTC facilities].

Interpretive Guidelines applies to: §403.748(c), §416.54(c), §418.113(c), §441.184(c),

§460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.625(c),

§485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c).

NOTE: This does not apply to Transplant Programs.

Facilities must have a written emergency communication plan that contains how the

facility coordinates patient care within the facility, across healthcare providers, and with

state and local public health departments. The communication plan should include how

the facility interacts and coordinates with emergency management agencies and systems

to protect patient health and safety in the event of a disaster. The development of a

communication plan will support the coordination of care. The plan must be reviewed

annually and updated as necessary. We are allowing facilities flexibility in how they

formulate and operationalize the requirements of the communication plan. Although the

requirement for documentation of collaboration with state and local officials was

removed (see 84 FR 51817, Sept. 30, 2019), facilities should still continue to collaborate

with state and local emergency officials. During the creation process for communication

plans, facilities should also consult their applicable state and local emergency and

pandemic plans.

Facilities in rural or remote areas with limited connectivity to communication

methodologies such as the Internet, World Wide Web, or cellular capabilities need to

ensure their communication plan addresses how they would communicate and comply

with this requirement in the absence of these communication methodologies. For

example, if a facility is located in a rural area, which has limited or no Internet and phone

connectivity during an emergency, it should address what alternate means are available to

alert local and State emergency officials. Optional communication methods facilities

may consider include satellite phones, radios and short wave radios.

Survey Procedures

• Verify that the facility has a written communication plan by asking to see the

plan.

• Ask to see evidence that the plan has been reviewed (and updated as necessary) at

least every 2 years (annually for LTC facilities).

• Ask facility leadership or the designee responsible for the emergency program to

verbally explain how they are to collaborate with Federal, State and local

officials to ensure their communication plan complies with the Federal, State and

local requirements.