Emergency Preparedness Training

Many skilled nursing facilities utilize a real-life activation of their emergency preparedness program as one of their disaster trainings as required by E Tag 0039 in CMS’ Appendix Z. With the, thankfully, calmer hurricane season this year, some providers may need to evaluate their disaster training in the absence of any emergency preparedness surrounding a hurricane watch, warning, or evacuation. 

As a reminder, Appendix Z has the following requirement for E Tag 0039:

(2)The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: 

(i) Participate in an annual full-scale exercise that is community-based; or 

(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. 

(B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. 

(ii) Conduct an additional annual exercise that may include, but is not limited to the following: 

(A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or 

(B) A mock disaster drill; or 

(C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. 

If a facility determines they need to participate in a community-based drill but cannot locate one, the facility will need to plan a functional exercise instead. It is important to note two requirements:

1. The facility must show they attempted to locate a community-based drill, or attempted to try and coordinate one with another facility in their area. 
2. The functional exercise would require the facility to physically act out the scenario. If the facility is going to simulate a loss of their electronic health record (EHR), for instance,  there would need to be nurses and CNAs who do some paper charting for a portion of their shift. The paper charting would then need to be entered into the EHR, and a complete after-action report would need to be documented.  

For questions about this topic, please contact FHCA’s Life Safety Consultant Clinton Slier.