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Emergency Preparedness Citation Trends

Posted Jun 4, 20191 min Read

Regulatory & Clinical

The CMS requirements of participation for emergency preparedness programs have 27 E-tags that facilities can be cited under. There are five categories the E-tags are placed, and they are as follows:  

  1. Establishing a comprehensive emergency preparedness Program
  2. Emergency Preparedness Policy and Procedures
  3. Emergency Preparedness Communication plan
  4. Emergency Preparedness Training and Testing
  5. Emergency and Standby Power Systems Requirements

The most frequently cited E-tags are in the category of Emergency Preparedness Policy and Procedures under the following tags:

E0015 – Subsistence Needs for Staff and Patients

E0026 – Roles Under a Waiver Declared by Secretary

E0024 – Policies and Procedures – Volunteers and Staffing

E0018 – Procedures for Tracking of Staff and Patients

Recommended Action:

  • Ensure the annual review of the policy and procedures for emergency preparedness are scheduled to be reviewed annually. The annual review must be documented.
  • Modify your policy and procedures with lessons learned from the training/drills that have occurred throughout the year. Include changes for improvements that enhance response in disaster and emergency situations.
  • Evaluate and recap each drill or emergency in an after-action report. (sample
  • Review the CMS Emergency Preparedness guidance for the above listed tags related to required policy and procedures by following this link.