Featured Standards FS.3.2.1 and 3.2.2: Emergency Evacuation Planning Revisited

Emergency evacuation drill requirements are nothing new, but we continue to see facility management overlooking or undervaluing them. For some, you might feel like your facility is too large and too busy to get all your employees through an annual evacuation drill and for others it may seem silly to have a drill when there are only a few employees working at your facility at any given time. However, conducting an emergency evacuation drill is still very important. In fact, it is so important that standard FS.3.2.2 must be completed annually AND not doing so will automatically result in the need for you to submit a Corrective Action Plan (CAP). 

FS.3.2.1: You must conduct an annual emergency evacuation drill in accordance with the evacuation plan. The drill(s) must be done at least annually for all staff on all shifts.

Additionally, standard FS.3.2.2 requires that you also evaluate the effectiveness of your emergency evacuation plan and annual drill as well as include the results in your performance management plan. 

FS.3.2.2: You must write an evaluation of the effectiveness of the emergency evacuation plan and annual drill. Results of the evaluation must be included in your performance management plan.

So, beyond getting dinged on your onsite survey, why is an emergency evacuation drill important for every facility? No matter how big or small your facility, a lot can change in one year. That has been particularly evident this past year during the pandemic. Your work environment may have changed (hello telehealth and telework!). You may have hired new staff or let some go. You may have taken on new patients with different mobility challenges, hearing or vision loss. Even the slightest changes can render a very effective evacuation plan obsolete. Any changes in your environment should instigate a new risk assessment and result in an updated plan but testing the new plan with an evacuation drill is the perfect way to check whether you got it right.

For example, it may become apparent during your drill that you need to install more emergency lighting or a new fire escape sign, or even invest in a new alarm with flashing beacons to warn deaf or hard of hearing patients or staff. Whatever your fire drill uncovers, it allows you the chance to correct it quickly in case of a real emergency.

OK, so you are now conducting an annual drill with all staff on all shifts – great! But, as you’ve heard us say time and time again…if it’s not documented, it didn’t happen. When writing your evaluation, be sure to include details like when and where the drill took place, who attended and the overall success of the drill, such as timeliness and staff performance. Your evaluation can be very simple and short if it includes these important details. You don’t even need to make your own evaluation sheet! Use our Fire/Emergency Drill Documentation template to get started and modify as needed.

Beyond being a requirement, drills can lead to saving valuable seconds in a real emergency, which can ultimately save lives or minimize destruction of property.  

If your business has the misfortune of experiencing an actual emergency that results in injury or tragic loss of life, failure to have conducted and documented required emergency procedures can result in additional legal entanglement and financial jeopardy. In short, paying attention to the details where safety is concerned is not only the right thing to do; it’s also good for business.  

For a deeper dive into this topic, be sure to revisit our Surveyor’s Notes on the Essentials of an Emergency Evacuation Plan