Annual Emergency Preparedness Plan Review

Annual inspection template for documenting review and update of an all-hazards emergency preparedness plan, including risk assessment, communication plan, training, drills, and corrective actions for CMS readiness.

Inspection Details

• Review date recorded
• Facility / department scope identified
• Reviewer name and title documented
• Plan version or revision date documented
• Applicable regulatory basis identified

All-Hazards Risk Assessment

• Risk assessment reviewed and updated for current hazards
• Facility-specific hazards identified and documented
• Likelihood and impact reviewed for each major hazard
• Mitigation actions updated with owners and due dates
• Changes in occupancy, services, equipment, or layout considered
• External hazard information reviewed

Emergency Communication Plan

• Emergency contact list reviewed and updated
• Primary and backup communication methods documented
• Communication plan includes staff, patients, residents, and families as applicable
• After-hours and weekend notification process documented
• Alternate communication method tested within the review period

Training, Drills, and Exercises

• Staff emergency preparedness training completed
• Drill or exercise records available for the review period
• At least one drill or exercise included evaluation of communication procedures
• Lessons learned documented and assigned for follow-up
• Competent person or designated leader reviewed drill outcomes

Plan Accessibility and Resources

• Current plan is accessible to staff in the work area
• Emergency roles and responsibilities are assigned
• Evacuation, shelter-in-place, and relocation procedures are current
• Emergency supplies and backup resources reviewed
• Mutual aid, vendor, or alternate site agreements reviewed if applicable

Findings, Corrective Actions, and Approval

• Deficiencies or non-conformances documented
• Corrective action owners and due dates assigned
• Final review approved by leadership
• Supporting documentation attached