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PDF Version of BQA 05-016 (PDF, 32 KB)

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Date: December 12, 2005 DDES-BQA-05-016

To: Facilities Serving People with Developmental Disabilities FDD 06
MPRO, Wisconsin Association of Homes and Services for the Aging

From: Jan Eakins, Chief, Provider Regulation and Quality Improvement Section

Via: Otis Woods, Director, Bureau of Quality Assurance

Clarification of "Quarterly" Evacuation Drills

The Centers for Medicare and Medicaid Services' Central Office in Baltimore has provided guidance on the timing requirement for ICF/MR evacuation drills. The BQA is distributing the CMS two-page interpretation with this memo. The interpretation no longer requires that drills be within an exact 90-day period. "Quarterly" in W440 - 42 CFR483.470(i)(1) is clarified to be "within a 3 consecutive month period". CMS provided an example drill schedule to further clarify the interpretation.

Federal Monitoring Surveys (FMSs) Change To Partnership Surveys

The Federal Monitoring and Oversight Contract with the Centers for Medicare and Medicaid Services ended September 30, 2005. Effective October 1, 2005, CMS will conduct nationwide Partnership FMSs under a new contract with Health Care Management Services, which uses some of the previous contract surveyors. Partnership surveys will focus on state-operated facilities of varying sizes, and will occur simultaneously with the state agency recertification surveys. The Partnership model is intended to assure accurate and consistent interpretation of federal ICF/MR regulations by state agency surveyors. It replaces the Look Behind FMS concept. The number of surveys conducted nationwide is expected to increase from approximately 70 FMS to approximately 100 Partnership surveys per year.

Please direct all questions regarding these issues to Jean Kollasch at 608-267-0466, or e-mail her at

Q2. How often must an ICF/MR conduct evacuation drills?

A2. While the regulation at W440 (42 CFR 483.470(i)(1)) states that evacuation drills must be conducted for each shift of staff at least "quarterly," the interpretive guidelines for W440 say "at least once in a 3-month period." Neither the regulation at W440 (42 CFR 483.470(i)(1)) nor its guidelines clarify this time span any further. They do not require that drills be conducted within a 90-day period. They do not require that drills be conducted during calendar quarters (January-March, April-June, July-September, October-December) or static quarters (same every year, every shift, every place). Because quarters are considered to be 3 consecutive months, the 3-month period referred to in W440 is considered to be 3 consecutive months. The month in which the first drill is completed establishes the beginning of the first quarter.

Therefore, the facility must conduct an evacuation drill during each shift of staff at least once within any consecutive 3-month period of the 12-month period. Put another way, a surveyor would expect to see no more than 3 consecutive months elapse between any evacuation drill on each shift. Therefore, as in the sample drill schedule below, if a facility held a drill for the first shift on February 3, a second drill would be expected at any time within the third consecutive month following February, or by the end of May. In other words, to be in compliance with W440, it would not be necessary for the next drill for that shift to be completed by May 3 as long as the drill is completed by May 31.

Explanation of Sample Drill Schedule

During each shift of staff, no more than a 3-month period elapses between some type of evacuation drill. For the first shift, various drills are planned and implemented with no more than 3 consecutive months between drills. Note: The drill is not required to be done within 90 days; rather, it should be completed at some point before the end of the third consecutive month after the first drill is completed. (See sample drill schedule on previous page.) For the second shift, a planned fire drill is conducted during January. An actual malfunction of a smoke alarm prompts staff to conduct and record a fire drill on March 25. The facility then adjusts its plans and conducts a tornado drill on June 3 to ensure that a drill is conducted within the third consecutive month. Other drills are planned and conducted to ensure that no more than 3 consecutive months elapse between drills. For the third shift, drills are planned and conducted with no more than a 3-consecutive-months period between any evacuation drill. An actual tornado warning results in an evacuation during the third shift in August, again prompting staff to record this as the response to a tornado drill. Note that a total evacuation of all persons served is planned and conducted once during the year on each shift.

Sample Drill Schedule

Month First Shift Second Shift Third Shift
January    Planned Fire Drill: January 6  
February Planned Fire Drill: February 3   Planned Fire Drill: February 16
March    Actual Smoke Alarm Malfunction (Used as Fire Drill): March 25  
May Planned Tornado Drill: May 12   Total Evacuation Drill: May 17
June   Planned Tornado Drill: June 3  
August  Planned Hurricane Drill: August 5    Actual Tornado Warning (Used as Tornado Drill): August 1
September    Planned Total Evacuation Drill: September 21  
November  Total Evacuation Drill: November 29    Planned Missing Person Drill: November 2
December    Planned Fire Drill: December 14  

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