Long-Term Care Survey Alert

Ensure your emergency plan supports regulatory requirements.

Make no mistake. Some aspects of emergency preparedness are survey sensitive. The Centers for Medicare & Medicaid Services (CMS) has a document that can help you navigate that overlap. Survey & Certification Emergency Preparedness for Every Emergency: Emergency Preparedness Checklist is designed to guide providers as they consider how the survey relates to disaster planning, including active shooter plans.

To ensure compliance, pay particular attention to the planning aspects below, says CMS.

Decision Criteria for Executing Plan 

Include factors to consider when deciding to evacuate or shelter in place. Determine who at the facility level will be in authority to make the decision to execute the plan to evacuate or shelter in place (even if no outside evacuation order is given) and what will be the chain of command.

Train Facility Staff Members 

Ensure that each facility staff member on each shift is trained to be knowledgeable and follow all details of the plan. Training also needs to address psychological and emotional aspects on caregivers, families, residents, and the community at large. Hold periodic reviews and appropriate drills and other demonstrations with sufficient frequency to ensure new members are fully trained.

Conduct Exercises & Drills 

Conduct exercises that are designed to test individual essential elements, interrelated elements, or the entire plan:

• Exercises or drills must be conducted at least semi-annually.
• Corrective actions should be taken on any deficiency identified.

Resident Identification 

Determine how residents will be identified in an evacuation and ensure the following identifying information will be transferred with each resident:

• Name
• Social security number
• Photograph
• Medicaid or other health insurer number
• Date of birth, diagnosis
• Current drug/prescription and diet regimens
• Name and contact information for next of kin/responsible person/Power of Attorney)

Determine how this information will be secured (e.g., laminated documents, water proof pouch around resident’s neck, waterproof wrist tag, etc.) and how medical records and medications will be transported so they can be matched with the resident to whom they belong.

Source: CMS, www.cms.gov/Medicare/Provider-Enrollment-and-certification/SurveyCertEmergPrep/Downloads/SandC_EPChecklist_Provider.pdf

For more information: For a copy of Incorporating Active Shooter Incident Planning into Health Care Facility Emergency Operations Plans, go to www.phe.gov/Preparedness/planning/Documents/active-shooter-planning-eop2014.pdf.