This federal CMS regulation requires multiple facility types—including PRTFs, CMHCs, hospitals, ICF/IIDs, and others—to develop, maintain, document, and periodically review an emergency preparedness training and testing program aligned with each facility's risk assessment, policies and procedures, and communication plan. Inpatient providers must conduct two testing exercises annually, while outpatient providers must conduct at least one annually (with a full-scale exercise at least every two years). LTC facilities must review their programs annually; all other covered facility types must review and update at least every two years. ICF/IIDs must additionally meet evacuation drill and training requirements under §483.470(i).
View official sourceE-0036 (Rev. 204, Issued: 04-16-21; Effective: 04-16-21, Implementation: 04-16-21) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(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). *[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).