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CMS Emergency Preparedness Rule Compliance Audit

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Audit of a healthcare facility's emergency preparedness program against the four core elements of the CMS Emergency Preparedness Rule.

CMS 42 CFR 482.15CMS 42 CFR 483.73CMS Emergency Preparedness Final Rule

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Emergency Plan & Risk Assessment

Is there a written emergency preparedness plan reviewed and updated at least every 2 years? *
Is the plan based on a documented facility- and community-based all-hazards risk assessment? *
Does the plan address the population served, including at-risk and mobility-impaired individuals? *
Does the plan include a process for cooperation with local, tribal, regional, and state officials? *

Are subsistence needs (food, water, medical, pharmaceutical supplies) addressed for staff and patients? *
Is there a system to track the location of on-duty staff and sheltered patients during an emergency? *
Are there policies for safe evacuation, including exit routes, transportation, and staff responsibilities? *
Is there a means to shelter in place for patients, staff, and volunteers? *
Are emergency power and stand-by systems addressed, including alternate sources of energy? *

Is there a communication plan reviewed and updated at least every 2 years? *
Does the plan include current contact info for staff, providers, volunteers, and other facilities? *
Is there a means of sharing patient information and medical documentation during transfer/evacuation? *
Is there a means to provide information about occupancy/needs to authorities (e.g., incident command)? *

Is initial emergency preparedness training provided and then annually thereafter? *
Are two exercises conducted annually, including one full-scale community-based exercise where available? *
Is a documented after-action review and improvement plan completed following each exercise or event? *
Date of most recent full-scale or tabletop exercise? *

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