This federal CMS emergency preparedness regulation requires facilities to maintain a communication plan that includes contact information for federal, state, tribal, regional, and local emergency preparedness staff and other assistance sources, reviewed and updated at least every two years (annually for long-term care facilities). The rule applies across a broad range of Medicare/Medicaid-certified provider types — including hospitals, hospices, home health agencies, ICF/IIDs, and others — and specifies additional contacts for LTC facilities (State Ombudsman, Licensing Agency) and ICF/IIDs (Protection and Advocacy Agency). Surveyors must verify that all required contacts are present, current, and accessible to leadership during emergencies.
View official sourceE-0031 (Rev. 204, Issued: 04-16-21; Effective: 04-16-21, Implementation: 04-16-21) §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). [(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.