Emergency Preparedness Plan Biennial Review for Clinic

Inspection template to review, update, and document the clinic’s all-hazards emergency preparedness plan at least every two years for RHC and FQHC compliance, including drills, communication, evacuation, sheltering, and corrective actions.

Inspection Details and Review Scope

• Review period and facility identification are documented
  Record the clinic name, site address, review date, and the two-year review period covered by this biennial inspection.
• Reviewer confirms this is a biennial emergency preparedness plan review
  Verify the review is being completed at least every two years and is not overdue.
• Applicable plan version and last update date are identified
  Document the current emergency preparedness plan version, approval date, and most recent revision date.

All-Hazards Risk Assessment and Plan Content

• All-hazards risk assessment is current and documented
  Confirm the plan includes a current all-hazards risk assessment addressing likely natural, technological, and human-caused emergencies relevant to the clinic.
• Emergency response procedures address evacuation, shelter-in-place, and lockdown
  Verify the plan contains specific procedures for evacuation, shelter-in-place, and lockdown or other protective actions as applicable.
• Patient, staff, and visitor protection measures are defined
  Confirm the plan identifies how patients, staff, and visitors will be protected during an emergency, including mobility assistance and special needs considerations.
• Emergency communication methods are documented and current
  Verify internal and external communication methods are listed, including primary and backup contact methods for staff, patients, emergency services, and leadership.
• Utility interruption and continuity procedures are included
  Confirm the plan addresses loss of power, water, HVAC, telecommunications, and other essential utilities, including continuity or relocation steps.

Emergency Contacts, Resources, and Accessibility

• Emergency contact list is complete and current
  Verify contact information for leadership, medical director, facility management, local emergency management, fire, police, EMS, utility providers, and alternate sites is current.
• Staff call tree or notification roster is maintained
  Confirm there is a current staff notification process or call tree with alternates and after-hours coverage.
• Emergency supplies and equipment list is documented
  Verify the plan identifies emergency supplies, backup power sources, medical supplies, water, flashlights, radios, and other essential items as applicable.
• Plan is accessible to staff during normal and after-hours operations
  Confirm the emergency preparedness plan and related procedures are available in a format staff can access during an emergency, including electronic and/or hard copy access.

Training, Testing, and Drill Documentation

• Required emergency training is documented for staff
  Verify staff training on emergency procedures, roles, and reporting expectations is documented and current.
• Tabletop or functional exercises are documented
  Confirm emergency preparedness exercises have been completed and documented according to the clinic’s testing schedule.
• Exercise findings and lessons learned were reviewed
  Verify after-action findings, gaps, and lessons learned from drills or actual events were incorporated into the plan review.
• Corrective actions from prior exercises are closed or tracked
  Confirm outstanding corrective actions are documented with owners and due dates, or are otherwise resolved.

Evacuation, Shelter, and Patient Tracking Procedures

• Evacuation routes and assembly points are documented
  Verify evacuation routes, exits, assembly areas, and relocation points are identified and current.
• Shelter-in-place procedures include location-specific instructions
  Confirm shelter-in-place procedures identify where staff and patients should go and what supplies or actions are required.
• Patient tracking and transfer procedures are documented
  Verify the plan includes a method for accounting for patients, visitors, and staff during evacuation or relocation, including transfer documentation if applicable.
• Special population and mobility assistance procedures are included
  Confirm the plan addresses patients requiring mobility assistance, language support, medical equipment, or other special accommodations.

Review Findings, Deficiencies, and Approval

• Deficiencies and non-conformances are documented
  Record any deficiencies, non-conformances, or missing elements identified during the review.
• Corrective action plan is assigned for each deficiency
  Verify each deficiency has an assigned corrective action, responsible owner, and target completion date.
• Plan update approval is documented
  Confirm the updated emergency preparedness plan is approved by appropriate leadership, such as the administrator or designee.
• Inspector signature is captured
  Signature of the reviewer completing the biennial inspection and plan review.