CMS SOM App. Z, Tag E-0035

*[For LTC Facilities at §483.73(c):]

[(c) The LTC 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 annually. The communication plan must include all

of the following:]

*[For ICF/IIDs at §483.475(c):]

[(c) The ICF/IID 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. The communication plan must include

all of the following:]

(8) A method for sharing information from the emergency plan, that the facility has

determined is appropriate, with residents [or clients] and their families or

representatives

.

Interpretive Guidelines for §483.73(c)(8) and §483.475(c)(8).

NOTE: This ONLY applies to LTC Facilities and ICF/IIDs.

LTC facilities and ICF/IIDs are required to share emergency preparedness plans and

policies with their residents/clients, family members, and resident representatives or

client representatives, respectively. Facilities have flexibility in deciding what

information from the emergency plan should be shared, as well as the timing and manner

in which it should be disseminated. While we are not requiring facilities take specific

steps or utilize specific strategies to share this information with residents or clients and

their families or representatives, we would recommend that facilities provide a quick

“Fact Sheet” or informational brochure to the family members and resident or client

representatives which may highlight the major sections of the emergency plan and

policies and procedures deemed appropriate by the facility. Other options include

providing instructions on how to contact the facility in the event of an emergency on the

public website or to include the information as part of the facility’s check-in procedures.

The facility may provide this information to the surveyor during the survey to

demonstrate compliance with the requirement.

Survey Procedures

• Ask staff to demonstrate the method the facility has developed for sharing the

emergency plan with residents or clients and their families or representatives.

• Interview residents or clients and their families or representatives and ask them if

they have been given information regarding the facility’s emergency plan.

• Verify the communication plan includes a method for sharing information from

the emergency plan, with residents or clients and their families or representatives

by reviewing the plan.