ICF/IID Emergency Preparedness Training: 42 CFR 483.475 Guide

If your agency runs an intermediate care facility for individuals with intellectual disabilities (ICF/IID), federal rules require an emergency preparedness program, and staff training is one of its four parts. The rule sits at 42 CFR 483.475, and surveyors check it the same way they check any other condition of participation: by reading your training files and asking staff what they would do.

This guide covers who has to be trained, how often, how to prove staff know the plan, the exercises and evacuation drills that go with the training, and how the timing compares for hospices, home health agencies and nursing homes.

Where the rule comes from

CMS's emergency preparedness final rule took effect on November 16, 2016, and providers had to comply by November 15, 2017. According to CMS, the requirements apply to 18 provider and supplier types, each with its own set of emergency preparedness regulations, and compliance is required to take part in Medicare or Medicaid. A September 30, 2019 final rule revised some of those requirements, including how often most provider types must retrain staff.

CMS's surveyor guidance for all of these provider types is Appendix Z of the State Operations Manual. The training requirement is survey tag E-0037.

The four parts of an ICF/IID program

Under 42 CFR 483.475, an ICF/IID must have:

1. An emergency plan based on a documented facility-based and community-based risk assessment that uses an all-hazards approach, including missing clients. The plan must address the special needs of the people you support and continuity of operations.
2. Policies and procedures built on that plan, covering things like food, water, medical and pharmaceutical supplies, tracking staff and clients during and after an emergency, safe evacuation, sheltering in place, and protecting client records.
3. A communication plan with contact information for staff, clients' physicians, other ICF/IIDs, volunteers, emergency management officials, the state licensing and certification agency, and the state protection and advocacy agency.
4. A training and testing program based on all three of the above.

Each of the four must be reviewed and updated at least every 2 years. Because the training has to follow your own plan, there is no single federal curriculum. What staff learn depends on the hazards your risk assessment found.

Who has to be trained

The training rule in 483.475(d)(1) reaches more people than many agencies expect. Initial training must go to:

• All new and existing staff
• People who provide services under arrangement, such as contracted clinicians
• Volunteers

Each person's training must be "consistent with their expected roles." Appendix Z says this includes people who work per diem or intermittently, such as agency nursing staff, if they would be expected to help during an emergency.

CMS also gives facilities room to set different levels of training by role. Appendix Z's example is dietary staff, who may need training on preparing and storing food in an emergency rather than on evacuation procedures. For a contractor who works at several facilities, such as a nutritionist, CMS leaves the delivery of training up to the facility, but expects that person to be able to describe your plan and their role if a surveyor asks.

How often: initial, every 2 years, and after big changes

The ICF/IID training program must do five things:

• Give initial training in emergency preparedness policies and procedures.
• Provide emergency preparedness training at least every 2 years.
• Keep documentation of the training.
• Demonstrate staff knowledge of emergency procedures.
• Train staff on updated policies and procedures whenever they are significantly updated.

Appendix Z recommends finishing initial training by the end of new-hire orientation, so it isn't delayed. When the plan changes, you don't have to retrain everyone on the whole program. CMS says facilities can train on just the new or revised parts, but every affected staff member must get that training.

Proving staff know the plan

Completion alone isn't enough. Appendix Z says documentation must show both the specific training completed and the method used to demonstrate knowledge. CMS lets facilities choose the method. A test at the end of a computer-based or printed module works, and so does a question-and-answer session after instructor-led training.

When surveyors review E-0037, Appendix Z tells them to:

• Ask for copies of your initial and refresher emergency preparedness trainings.
• Interview staff about the training to check their knowledge of emergency procedures.
• Review a sample of staff training files.

CMS recommends keeping at least the past two cycles of training and exercise records, which is generally 4 years, so you can show that the program has been updated on schedule.

Exercises: testing the plan twice a year

Training goes with testing. Under 483.475(d)(2), an ICF/IID must run exercises to test its emergency plan at least twice a year:

• One annual full-scale exercise that is community-based, or, when a community-based exercise isn't available, an individual facility-based functional exercise.
• One additional annual exercise, which can be a second full-scale or functional exercise, a mock disaster drill, or a facilitator-led tabletop exercise built around a realistic emergency scenario.

If a real emergency requires you to activate your plan, you're exempt from the next required full-scale or functional exercise. Either way, you must analyze your response to every drill, tabletop exercise and real event, keep documentation, and revise the plan as needed.

Evacuation drills every quarter, on every shift

The emergency preparedness rule also points back to the ICF/IID evacuation drill standard at 42 CFR 483.470(i). That standard requires:

• Evacuation drills at least quarterly for each shift, under varied conditions, so that all staff on all shifts are trained in their assigned tasks and know the building's fire protection features.
• Actually evacuating clients during at least one drill each year on each shift.
• Special provisions for evacuating clients with physical disabilities.
• A written report and evaluation for each drill, plus investigation and corrective action for any problems, including accidents.
• The same drill requirements for live-in and relief staff.

For DSPs, this is where training becomes real. A quarterly drill on the overnight shift is often the moment a new hire learns where the person who uses a wheelchair needs help, or which door sticks.

How the timing compares for other provider types

The same training language appears across most provider types, but the refresher interval isn't the same everywhere. According to Appendix Z:

Every one of these still requires initial training, documentation, and a way to show staff know the procedures. If your organization runs both an ICF/IID and a nursing home, keep the two schedules separate in your tracking system.

Community programs funded through Medicaid home and community-based services (HCBS) waivers aren't in this table. If that's your setting, check your state's licensing and waiver rules for emergency plan, drill and training requirements.

A quick checklist for managers

• Your risk assessment lists your real hazards, including people going missing, and the training covers them.
• Every new hire, contractor and volunteer gets initial training during orientation, matched to their role.
• Refresher training is scheduled at least every 2 years (annually for nursing homes).
• Each training record shows what was covered and how knowledge was checked.
• Staff are retrained whenever the policies and procedures change significantly.
• Two exercises a year are documented, with an after-action review.
• Quarterly evacuation drills happen on every shift, with at least one real evacuation per shift each year and a written evaluation of each drill.
• At least two cycles of records, about 4 years, are kept for surveyors.

How TES helps

Our catalog includes courses that cover general emergency and fire safety content for care teams, including:

• Emergency Preparedness
• Fire Safety for Direct Support Professionals
• Fire and Life Safety
• Emergency Disaster Plans for Senior Care Professionals
• Employee Safety and Emergency Preparedness in Hospice Care

General courses build a foundation, but CMS expects training to follow your own emergency plan, risk assessment and communication plan. Pair any course with a site-specific review of your plan, and keep your drill and exercise records alongside the training records.

Training & eTracking Solutions has trained more than 200,000 professionals since 2010, and our catalog includes 400+ courses and programs. As an NADSP Accredited Education provider, our courses count toward the DSP-I and DSP-II credentials. For a broader look at building a fire safety review, see Fire Safety 101. To keep initial and refresher dates current for every staff member without spreadsheets, read how to track employee training in a care agency, or contact us to set up training for your team.

This article summarizes 42 CFR 483.475 and 483.470(i) as published in the Electronic Code of Federal Regulations, and CMS State Operations Manual Appendix Z (Rev. 204, issued April 16, 2021). It is not legal advice. State licensing rules and surveyors may add requirements, and rules change, so check the current text before making compliance decisions.