E-0037: Training Program Under this requirement, facilities must provide both initial training and annual reviews in emergency preparedness policies and procedures that are consis- tent with each individual’s roles in an emergency. Training must be provided to all new and existing staff, individu- als providing services under arrange- ment, individuals who provide services on a per diem basis and volunteers, and it must be documented. It is up to the facility to decide what level of training each staff member will be required to complete each year based on an individ- ual’s involvement or expected role dur- ing an emergency. CMS recommends that for new hires, this be completed by the time the staff has completed the facility’s new hire orientation program. ASCs have some flexibility as to the focus of their annual training, as long as it aligns with the emergency plan and risk assessment. CMS rec- ommends annual training be modi- fied every year, incorporating lessons learned from recent exercises and any real-life emergencies that occurred in the past year. For example, annual training could include training staff on new evacuation procedures that were identified as a best practice and doc- umented in the facility “After Action Report” (AAR) during the last emer- gency drill and were incorporated into the emergency plan during the program’s annual review. Under this E-tag, surveyors will: ■■

Ask for copies of the facility’s ini- tial emergency preparedness training and annual emergency preparedness training offerings.


Interview various staff and ask questions

regarding the facility’s

initial and annual training course, to verify staff knowledge of emer- gency procedures.


Review a sample of staff training files to verify staff have received initial and annual emergency pre- paredness training.

The Centers for Disease Control

and Prevention (CDC) provide several training and educational resources for specific emergencies such as bioterror- ism and chemical emergencies, as well as trainings targeted to specific audi- ences such as public health profession- als and clinicians. Additional resources are available through CDC’s Clinician Outreach and Communication Activity (COCA) program.

The Federal Emergency Man-

agement Agency (FEMA) also sup- plies many training courses through its Emergency Management Institute. There are web-based training courses that come out roughly every week, as well as a comprehensive course catalog that combines all FEMA emergency preparedness resources in one place.

E-0039: Testing Requirements Facilities must conduct exercises to test the emergency plan on an annual basis and document that these tests occurred. Whereas under previous requirements one test per year sufficed, as of Novem- ber 15, 2017, ASCs must conduct at least two tests. The first exercise should be a community-based drill, if avail- able, but regardless it must be a full- scale exercise. For the purposes of this requirement, a “full scale exercise is defined and accepted as any operations- based exercise (drill, functional, or full- scale exercise) that assesses a facility’s

Track the Latest Regulatory and Legislative News for ASCs

Visit ASCA’s website every week to stay up to date on the latest government affairs news affecting the ASC industry. Every week, ASCA’s Government Affairs Update newsletter is posted online for ASCA members to read. The weekly newsletter tracks and analyzes the latest legislative and regulatory developments concerning ASCs. GovtAffairsUpdate

functional capabilities by simulating a response to an emergency that would impact the facility’s operations and their given community.”

If a community drill is not avail- able, CMS will require an ASC to con- duct an individual facility-based drill. For the second exercise, an ASC would be required to conduct either a facility- based drill or a tabletop exercise. If the facility had an actual emergency dur- ing the year, that can count toward this testing requirement. Under this E-tag, surveyors will: ■■

Ask to see documentation of the annual tabletop and full-scale exer- cises (which may include, but is not limited to, the exercise plan, the AAR, and any additional documen- tation used by the facility to support the exercise.


Ask to see the documentation of the facility’s efforts to identify a full- scale community-based exercise if it did not participate in one (i.e., date and personnel and agencies con- tacted and the reasons for the inabil- ity to participate in a community- based exercise).

Request documentation of the facil- ity’s analysis and response and how the facility updated its emergency program based on this analysis. For additional information and tools, visit the CMS Survey & Cer- tification Emergency Preparedness website at Provider-Enrollment-and-Certifica- tion/SurveyCertEmergPrep/index.html or ASPR TRACIE.

■■ ASCA also has customized a CMS-

developed spreadsheet that identifies all parts of the rule and interpretive guidelines applicable to ASCs. That document is available to our members at document/emergency-preparedness- surveyor-too.

Kara Newbury is ASCA’s regulatory counsel. Write her at


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