CMS SOM App. Z, Tag E-0036

§483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.625(d), §485.727(d),

§485.920(d), §486.360(d), §491.12(d), §494.62(d).

*[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184,

PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, CAHs at

§486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and

RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and

maintain an emergency preparedness training and testing program that is based on

the emergency plan set forth in paragraph (a) of this section, risk assessment at

paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this

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

and testing program must be reviewed and updated at least every 2 years.

*[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must

develop and maintain an emergency preparedness training and testing program that

is based on the emergency plan set forth in paragraph (a) of this section, risk

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

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

training and testing program must be reviewed and updated at least annually.

*[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and

maintain an emergency preparedness training and testing program that is based on

the emergency plan set forth in paragraph (a) of this section, risk assessment at

paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this

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

and testing program must be reviewed and updated at least every 2 years. The

ICF/IID must meet the requirements for evacuation drills and training at

§483.470(i).

*[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis

facility must develop and maintain an emergency preparedness training, testing and

patient orientation program that is based on the emergency plan set forth in

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

policies and procedures at paragraph (b) of this section, and the communication

plan at paragraph (c) of this section. The training, testing and orientation program

must be evaluated and updated at every 2 years.

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

§441.184(d), §482.15(d), §460.84(d), §483.73(d), §483.475(d), §484.102(d),

§485.68(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d),

§494.62(d).

NOTE: This does not apply to Transplant Programs.

Training and Testing Program- General

An emergency preparedness training and testing program as specified in this requirement

must be documented, reviewed and updated. The training and testing program must

reflect the risks identified in the facility’s risk assessment and be included in their

emergency plan. For example, a facility that identifies flooding as a risk should also

include policies and procedures in their emergency plan for closing or evacuating their

facility and include these in their training and testing program. This would include, but is

not limited to, training and testing on how the facility will communicate the facility

closure to required individuals and agencies, testing patient tracking systems and testing

transportation procedures for safely moving patients to other facilities. Additionally, for

facilities with multiple locations, such as multi-campus or multi-location hospitals, the

facility’s training and testing program must reflect the facility’s risk assessment for each

specific location.

Training Component

Training refers to a facility’s responsibility to provide education and instruction to staff,

contractors, and facility volunteers to ensure all individuals are aware of the emergency

preparedness program. For training requirements, the facility must have a process

outlined within its emergency preparedness program which encompasses staff and

volunteer training complementing the risk assessment. The training for staff should at a

minimum include training related to the facility’s policies and procedures. Facilities

must maintain documentation of the training so that surveyors are able to clearly

identify staff training and testing conducted. For example, facilities may have a sign-in

roster of training conducted within their training files or inclusion of this training in their

training program, or individual training certificates of completion within personnel

records. A surveyor should be able to ask for a list of employees and to verify training on

the emergency preparedness requirements as required under E-0037 (subsection

(d)(1)(iii).

Testing Component

Testing requirements vary based on the provider type. Inpatient providers are required

to conduct two testing exercises annually. Outpatient providers are required to conduct

one testing exercise annually (that at least every two years their exercise must be a full-scale exercise)- Refer to E-0039 (subsection (d)(2)).

Testing is the concept in which training is operationalized and the facility is able to

evaluate the effectiveness of the training as well as the overall emergency preparedness

program. Testing includes conducting drills and/or exercises to test the emergency plan

to identify gaps and areas for improvement. Additionally, facilities should establish a

process which includes participation of all staff in testing exercises over a period of time.

Facilities are encouraged to consider their scheduled exercises and the appropriate

departments to be included. For instance, if a clinically-relevant testing exercise is not

necessarily applicable to some other departments or staff, then the staff which did not

participate in one year should participate in the next testing exercise to ensure that over

a period of time all shifts are incorporated. Additionally, we are not specifying a facility

to utilize all required equipment in the testing (drills) or a percentage of the

patients/residents that would be included in these drills, however facilities should test

their exercises according to how they would respond to the emergency would it be an

actual real emergency.

Under this standard, surveyors are to assess whether or not the facility has a training

and testing program based on the facility’s risk assessment and has incorporated its

policies and procedures, as well as its communication plan within training required for

staff and its testing exercises.

Survey Procedures

• Verify that the facility has a written training and testing (and for ESRD facilities, a

patient orientation) program that meets the requirements of the regulation.

• Refer back to the facility’s risk assessment to determine if the training and testing

program is reflecting risks and hazards identified within the facility’s program.

• Verify the program has been reviewed and updated at least every 2 years (annually

for LTC facilities) by asking for documentation of the annual review as well as any

updates made.

• Verify that ICF/IID emergency plans also meet the requirements for evacuation drills

and training at §483.470(i).