CMS SOM App. Z, Tag E-0030

§482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1),

§485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1),

§494.62(c)(1).

[(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]. The

communication plan must include all of the following:]

(1) Names and contact information for the following:

(i) Staff.

(ii) Entities providing services under arrangement.

(iii) Patients' physicians

(iv) Other [facilities].

(v) Volunteers.

*[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must

include all of the following:

(1) Names and contact information for the following:

(i) Staff.

(ii) Entities providing services under arrangement.

(iii) Patients' physicians

(iv) Other [hospitals and CAHs].

(v) Volunteers.

*[For RNHCIs at §403.748(c):] The communication plan must include all of the

following:

(1) Names and contact information for the following:

(i) Staff.

(ii) Entities providing services under arrangement.

(iii) Next of kin, guardian, or custodian.

(iv) Other RNHCIs.

(v) Volunteers.

*[For ASCs at §416.45(c):] The communication plan must include all of the

following:

(1) Names and contact information for the following:

(i) Staff.

(ii) Entities providing services under arrangement.

(iii) Patients’ physicians.

(iv) Volunteers.

*[For Hospices at §418.113(c):] The communication plan must include all of the

following:

(1) Names and contact information for the following:

(i) Hospice employees.

(ii) Entities providing services under arrangement.

(iii) Patients’ physicians.

(iv) Other hospices.

*[For HHAs at §484.102(c):] The communication plan must include all of the

following:

(1) Names and contact information for the following:

(i) Staff.

(ii) Entities providing services under arrangement.

(iii) Patients’ physicians.

(iv) Volunteers.

*[For OPOs at §486.360(c):] The communication plan must include all of the

following:

(2) Names and contact information for the following:

(i) Staff.

(ii) Entities providing services under arrangement.

(iii)Volunteers.

(iv) Other OPOs.

(v) Transplant and donor hospitals in the OPO’s Donation Service Area

(DSA).

Interpretive Guidelines applies to: §403.748(c)(1), §416.54(c)(1), §418.113(c)(1),

§441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1),

§484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1),

§486.360(c)(1), §491.12(c)(1), §494.62(c)(1).

NOTE: This does not apply to Transplant Programs.

A facility must have the contact information for those individuals and entities outlined

within the standard. The requirement to have contact information for “other facilities”

requires a provider or supplier to have the contact information for another provider or

supplier of the same type as itself. For instance, hospitals should have contact

information for other hospitals and CORFs should have contact information for other

CORFs, etc. While not required, facilities may also find it prudent to have contact

information for other facilities not of the same type. For instance a hospital may find it

appropriate to have the contact information of LTC facilities within a reasonable

geographic area, which could assist in facilitating patient transfers. Facilities have

discretion in the formatting of this information, however it should be readily available

and accessible to leadership, at a minimum, to the individual(s) designated as the

emergency preparedness coordinator or person(s) responsible for the facility’s

emergency preparedness program and management during an emergency event, during

an emergency event.

Facilities which utilize electronic data storage should be able to provide evidence of data

back-up with hard copies or demonstrate capability to reproduce contact lists or access

this data during emergencies. All contact information must be reviewed and updated as

necessary at least every 2 years, annually for LTC facilities. Contact information

contained in the communication plan must be accurate and current. Facilities must

update contact information for incoming new staff and departing staff throughout the year

and any other changes to information for those individuals and entities on the contact list.

Transplant programs should be included in the development of the hospitals

communication plans. In the case of a Medicare-approved transplant program, a

communication plan needs to be developed and disseminated between the hospitals,

OPO, and transplant patients. For example, if the transplant program is planning to

transfer patients to another transplant program due to an emergency, the communication

plan between the hospitals, the OPO, and the patient should include the responsibilities of

each of the facility types to ensure continuity of care. During an emergency, should an

organ offer become available at the time the patient is at the “transferred hospital,” the

OPO’s emergency preparedness communication plan should address how this

information will be communicated to both the OPO and the patient of where their care

will be continued.

NOTE: For Home Health Agencies, contact information should also include patient’s

physicians or allowed practitioners. Section 484.60 requires that each patient’s written

plan of care specify the care and services necessary to meet the patient specific needs

identified in the comprehensive assessment. Accordingly, additional practitioners at

HHAs should also be notified to reflect the interdisciplinary, coordinated approach to

home health care delivery consistent with the HHA regulations.

Survey Procedures

• Verify that all required contacts are included in the communication plan by asking

to see a list of the contacts with their contact information.

• Verify that all contact information has been reviewed and updated at least every 2

years (annually for LTC facilities) by asking to see evidence of the review.