This federal CMS regulation requires facilities to establish and maintain emergency preparedness training programs for all staff, contracted individuals, and volunteers. Facilities must provide initial training consistent with each person's expected role, conduct refresher training at least every two years (annually for long-term care), demonstrate staff knowledge of emergency procedures, and maintain documentation of all training. Additional training is required whenever emergency preparedness policies and procedures are significantly updated.
View official sourceE-0037 (Rev. 204, Issued: 04-16-21; Effective: 04-16-21, Implementation: 04-16-21) §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). *[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.