CMS SOM App. Z, Tag E-0031

§482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2),

§485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2),

§494.62(c)(2).

[(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:

(2) Contact information for the following:

(i) Federal, State, tribal, regional, and local emergency preparedness staff.

(ii) Other sources of assistance.

*[For LTC Facilities at §483.73(c):] (2) Contact information for the following:

(i) Federal, State, tribal, regional, and local emergency preparedness staff.

(ii) The State Licensing and Certification Agency.

(iii) The Office of the State Long-Term Care Ombudsman.

(iv) Other sources of assistance.

*[For ICF/IIDs at §483.475(c):] (2) Contact information for the following:

(i) Federal, State, tribal, regional, and local emergency preparedness staff.

(ii) Other sources of assistance.

(iii) The State Licensing and Certification Agency.

(iv) The State Protection and Advocacy Agency.

Interpretive Guidelines applies to: §403.748(c)(2), §416.54(c)(2), §418.113(c)(2),

§441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2),

§484.102(c)(2), §485.68(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2),

§486.360(c)(2), §491.12(c)(2), §494.62(c)(2).

NOTE: This does not apply to Transplant Programs.

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

within the standard. Emergency management officials may include, but are not limited

to, emergency management agencies which may be local to the community as well as

local officials who support the Incident Command System depending on the nature of the

disaster (e.g. fire, police, public health, etc.). Additionally, emergency management

officials also include the state public health departments and State Survey Agencies as

well as federal emergency preparedness officials (FEMA, ASPR, DHS, CMS, etc.) and

tribal emergency officials, as applicable.

Facilities have discretion in the formatting of this information, however it should be

readily available and accessible to leadership during an emergency event. Facilities are

encouraged but not required to maintain these contact lists both in electronic format and

hard-copy format in the event that network systems to retrieve electronic files are not

accessible. All contact information must be reviewed and updated at least every 2 years

(annually, for LTC facilities).

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 the facility has contact information for the State Survey Agency and/or

public health departments.

• Verify that all contact information has been reviewed and updated at least in the

past 2 years (annually for LTC facilities) by asking to see evidence of the review.

NOTE: Even though the communications plan must include contact information, it does

not specifically require the facility to have an individual contact for emergency

management agencies. For instance, a state emergency management agency may have a

specific phone line or contact method and not a specific individual person.