CMS SOM App. Z, Tag E-0037

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

§485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1).

*[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at

§483.475, HHAs at §484.102, “Organizations” under §485.727, OPOs at §486.360,

RHC/FQHCs at §491.12:]

(1) Training program. The [facility] must do all of the following:

(i) Initial training in emergency preparedness policies and procedures to all

new and existing staff, individuals providing services under arrangement,

and volunteers, consistent with their expected roles.

(ii) Provide emergency preparedness training at least every 2 years.

(iii) Maintain documentation of all emergency preparedness training.

(iv) Demonstrate staff knowledge of emergency procedures.

(v) If the emergency preparedness policies and procedures are significantly

updated, the [facility] must conduct training on the updated policies and

procedures.

*[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the

following:

(i) Initial training in emergency preparedness policies and procedures to all

new and existing hospice employees, and individuals providing services

under arrangement, consistent with their expected roles.

(ii) Demonstrate staff knowledge of emergency procedures.

(iii) Provide emergency preparedness training at least every 2 years.

(iv) Periodically review and rehearse its emergency preparedness plan with

hospice employees (including nonemployee staff), with special emphasis

placed on carrying out the procedures necessary to protect patients and

others.

(v) Maintain documentation of all emergency preparedness training.

(vi) If the emergency preparedness policies and procedures are significantly

updated, the hospice must conduct training on the updated policies and

procedures.

*[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the

following:

(i) Initial training in emergency preparedness policies and procedures to all

new and existing staff, individuals providing services under arrangement,

and volunteers, consistent with their expected roles.

(ii) After initial training, provide emergency preparedness training every 2

years.

(iii) Demonstrate staff knowledge of emergency procedures.

(iv) Maintain documentation of all emergency preparedness training.

(v)

If the emergency preparedness policies and procedures are significantly

updated, the PRTF must conduct training on the updated policies and

procedures.

*[For PACE at §460.84(d):] (1) The PACE organization must do all of the following:

(i) Initial training in emergency preparedness policies and procedures to all

new and existing staff, individuals providing on-site services under

arrangement, contractors, participants, and volunteers, consistent with their

expected roles.

(ii) Provide emergency preparedness training at least every 2 years.

(iii) Demonstrate staff knowledge of emergency procedures, including

informing participants of what to do, where to go, and whom to contact in

case of an emergency.

(iv) Maintain documentation of all training.

(v) If the emergency preparedness policies and procedures are significantly

updated, the PACE must conduct training on the updated policies and

procedures.

*[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do

all of the following:

(i) Initial training in emergency preparedness policies and procedures to all

new and existing staff, individuals providing services under arrangement,

and volunteers, consistent with their expected role.

(ii) Provide emergency preparedness training at least annually.

(iii) Maintain documentation of all emergency preparedness training.

(iv) Demonstrate staff knowledge of emergency procedures.

*[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following:

(i) Provide initial training in emergency preparedness policies and

procedures to all new and existing staff, individuals providing services under

arrangement, and volunteers, consistent with their expected roles.

(ii) Provide emergency preparedness training at least every 2 years.

(iii) Maintain documentation of the training.

(iv) Demonstrate staff knowledge of emergency procedures. All new

personnel must be oriented and assigned specific responsibilities regarding

the CORF’s emergency plan within 2 weeks of their first workday. The

training program must include instruction in the location and use of alarm

systems and signals and firefighting equipment.

(v) If the emergency preparedness policies and procedures are significantly

updated, the CORF must conduct training on the updated policies and

procedures.

*[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the

following:

(i) Initial training in emergency preparedness policies and procedures,

including prompt reporting and extinguishing of fires, protection, and where

necessary, evacuation of patients, personnel, and guests, fire prevention, and

cooperation with firefighting and disaster authorities, to all new and existing

staff, individuals providing services under arrangement, and volunteers,

consistent with their expected roles.

(ii) Provide emergency preparedness training at least every 2 years.

(iii) Maintain documentation of the training.

(iv) Demonstrate staff knowledge of emergency procedures.

(v) If the emergency preparedness policies and procedures are significantly

updated, the CAH must conduct training on the updated policies and

procedures.

*[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial

training in emergency preparedness policies and procedures to all new and existing

staff, individuals providing services under arrangement, and volunteers, consistent

with their expected roles, and maintain documentation of the training. The CMHC

must demonstrate staff knowledge of emergency procedures. Thereafter, the

CMHC must provide emergency preparedness training at least every 2 years.

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

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

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

§486.360(d)(1), §491.12(d)(1)

NOTE: This does not apply to Transplant Programs or ESRD facilities.

Training Program- General

Facilities are required to provide initial training in emergency preparedness policies and

procedures that are consistent with their roles in an emergency to all new and existing

staff, individuals providing services under arrangement, and volunteers. This includes

individuals who provide services on a per diem basis such as agency nursing staff and

any other individuals who provide services on an intermittent basis and would be

expected to assist during an emergency.

The training provided by the facility must be based on the facility’s risk assessment

policies and procedures as well as the communication plan. The intent is that staff,

volunteers and individuals providing services at the facility are familiar and trained on

the facility’s processes for responding to an emergency. Training should include

individual-based response activities in the event of a natural disasters, such as what the

process is for staff in the event of a forecasted hurricane. It should also include the

policies and procedures on how to shelter-in-place or evacuate. Training should include

how the facility manages the continuity of care to its patient population, such as triage

processes and transfer/discharge during mass casualty or surge events.

Furthermore, the facility must train staff based on the facility’s risk assessment. Training

for staff should mirror the facility’s emergency plan and should include training staff on

procedures that are relevant to the hazards identified. For example, for EID’s this may

include proper use of PPE, assessing needs of patients and how to screen patients and

provide care based on the facility’s capacity and capabilities and communications

regarding reporting and providing information on patient status with caregiver and

family members.

Facilities should provide initial emergency training during orientation (or shortly

thereafter) to ensure initial training is not delayed.

Continued Training

After the initial training has been conducted for staff, facilities must provide training on

their facility’s emergency plan at least every 2 years (except for LTC facilities which will

still be required to provide training annually). Facilities have the flexibility to determine

the focus of their initial and 2-year training, as long as it aligns with the emergency plan

and risk assessment. Initial and subsequent training should be modified as needed and if

the facility updates the policies and procedures to include but not limited to incorporating

any lessons learned from the most recent exercises and real-life emergencies that

occurred in and during the review of the facility’s emergency program, we would expect

the facility be able to demonstrate how they have updated the training as well. For

example, the 2 year subsequent training could include training staff on new evacuation

procedures that were identified as a best practice and documented in the facility “After

Action Report” (AAR) during the last emergency drill and were incorporated into the

emergency plan during the program’s review.

While facilities are required to provide initial and subsequent (at least every 2 years

except for LTC facilities which will still be required to provide training annually) training

to all staff, it is up to the facility to decide what level of training each staff member will

be required to complete based on an individual's involvement or expected role during an

emergency. There may be core topics that apply to all staff, while certain clinical staff

may require additional topics. For example, dietary staff who prepare meals may not

need to complete annual training that is focused on patient evacuation procedures.

Instead, the facility may provide training that focuses on the proper preparation and

storage of food in an emergency. In addition, depending on specific staff duties during

an emergency, a facility may determine that documented external training is sufficient to

meet some or all of the facility's training requirements. For example, staff who work

with radiopharmaceuticals may attend external training that teach staff how to handle

radiopharmaceutical emergencies. It is up to the facility to decide if the external training

meets the facility’s requirements.

Facilities must also be able to demonstrate additional training when the emergency plan

is significantly updated. Facilities which may have changed their emergency plan should

plan to conduct initial training to all staff on the new or revised sections of the plan. If a

facility determines the need to add additional policies and procedures based on a new

risk identified in the facility’s risk assessment, the facility must train all staff on the new

policies and procedures and the staff responsibilities. Facilities are not required to re-train staff on the entire emergency plan, but can choose to train staff on the new or

revised element of the emergency preparedness program. For example, a facility

identifies during an influenza outbreak that additional policies and procedures and

adjustments to the risk assessment are needed to address a significant influx of

patients/clients/residents. The facility identifies clinical locations in which contagious

patients can be triaged in a manner to minimize exposure to non-infected individuals.

The training for this new or revised policy can be done without needing to re-train staff

on the entire program.

Variance by Provider/Supplier Type

PACE organizations and CAHs have additional requirements. PACE organizations must

also provide initial training to contractors and PACE participants. CAHs must also

include initial training on the following: prompt reporting and extinguishing of fires;

protection; and where necessary, evacuation of patients, personnel, and guests, fire

prevention, and cooperation with firefighting and disaster authorities.

With the exception of CORFs which must complete initial training within the first two

weeks of employment, we recommend initial training be completed by the time the staff

has completed the facility’s new hire orientation program. Additionally, in the case of

facilities with multiple locations, such as multi-campus hospitals, staff, individuals

providing services under arrangement, or volunteers should be provided initial training at

their specific location and when they are assigned to a new location.

LTC facilities must continue to provide initial and continued training on an annual basis.

Training of Volunteers and Contracted Staff

Facilities may contract with individuals providing services who also provide services in

multiple surrounding areas. For instance, an ICF/IID may contract a nutritionist who also

provides services in other locations. Given that these contracted individuals may provide

services at multiple facilities, it may not be feasible for them to receive formal training

for each of the facilities for emergency preparedness programs. The expectation is that

each individual knows the facility’s emergency program and their role during

emergencies, however the delivery of such training is left to the facility to determine.

Facilities in which these individuals provide services may develop some type of training

documentation- i.e. the facility’s emergency plan, important contact information, and the

facility’s expectation for those individuals during an emergency etc. which documents

that the individual received the information/training. Furthermore, if a surveyor asks one

of these individuals what their role is during a disaster, or any relevant questions, then the

expectation is that the individual can describe the emergency plans/their role.

Documentation Requirements

Facilities must maintain documentation of the initial and subsequent (at least every 2

years except for LTC facilities which will still be required to provide training annually)

training for all staff. The documentation must include the specific training completed as

well as the methods used for demonstrating knowledge of the training program. Facilities

have flexibility in ways to demonstrate staff knowledge of emergency procedures. The

method chosen is likely based on the training delivery method. For example: computer-based or printed self-learning packets may contain a test to demonstrate knowledge. If

facilities choose instructor-led training, a question and answer session could follow the

training. Regardless of the method, facilities must maintain documentation that training

was completed and that staff are knowledgeable of emergency procedures.

Survey Procedures

• Ask for copies of the facility’s initial and subsequent (at least every 2 years or annual

for LTC) emergency preparedness trainings and annual emergency preparedness

training offerings.

• Interview various staff and ask questions regarding the facility’s initial and

subsequent (at least every 2 years or annual for LTC) training course to verify staff

knowledge of emergency procedures.

• Review a sample of staff training files to verify staff have received initial and

subsequent (at least every 2 years or annual for LTC), emergency preparedness

training.

NOTE: For ease of demonstrating compliance that the facility has updated its training

program at least every 2 years, we recommend that facilities retain at a minimum, the

past 2 cycles (generally 4 years) of emergency training documentation for both training

and exercises for surveyor verification.