Hospice · CMS survey prep

Hospice Emergency Preparedness Plan Template: Meeting §418.113 Before Your Next Survey

September 10, 2026 · 9 min read

Photo by Jsme MILA · Pexels

Hospice agencies are under more scrutiny right now than at any point in the last decade. Between increased OIG audit activity, post-pandemic survey backlogs clearing out, and the regulatory groundwork laid by the Special Focus Program—which targeted underperforming hospices before its suspension in early 2025—surveyors are paying closer attention than ever. Emergency preparedness is one of the first things they check.

The problem? Most hospice administrators inherited their EP binder from someone who left two jobs ago. The plan hasn't been updated. The risk assessment is missing. The last drill has no documentation. And the surveyor doesn't care about good intentions—they care about what's on paper.

This guide walks through every emergency preparedness requirement under 42 CFR §418.113 so you know exactly what needs to be in your binder when that surveyor arrives.

Hospice vs. Home Health: What's Different?

If you've seen emergency preparedness guidance for home health agencies, you might think the hospice requirements are identical. They're close, but not quite. Inpatient hospice facilities carry additional requirements that home-based hospices don't—shelter-in-place plans, patient tracking systems, and provisions for food, water, and alternate power. Exercise frequency also differs: inpatient hospices must conduct exercises twice a year, while home-based hospices test annually, same as home health. And the patient population itself changes the calculus, because hospice patients are by definition at end of life. Their evacuation needs, medication dependencies, and family communication plans carry different weight than those of a patient receiving skilled nursing visits at home.

The rest of the structure follows the same four elements CMS uses for all 17 provider types. Here's what each one requires of a hospice agency.

The Emergency Plan

The regulation at §418.113(a) requires you to develop and maintain a written emergency preparedness plan, reviewed and updated at least every two years.

Start with the risk assessment. You need a documented, facility-based and community-based assessment using an all-hazards approach—natural hazards specific to your geography, man-made threats like infrastructure failures or hazmat incidents, facility-specific risks such as what happens if your inpatient unit loses power or your EHR goes down, and emerging infectious disease scenarios. This is a standalone document. It needs to exist separately from your plan, and the plan needs to reference it. Surveyors check for this.

For every hazard you identified, your plan needs an actual response strategy—not a generic statement like "we will respond appropriately," but a description of what your agency will do. Think about what makes your patients uniquely vulnerable: patients on continuous medication infusions who can't miss doses, patients on home oxygen who need electricity, patients whose families are their primary caregivers and might not be able to stay, patients in rural areas where roads flood or become impassable. Each of those scenarios needs a written answer.

Your plan must also address continuity of operations—who runs the show if the administrator is unreachable, with clear delegations of authority and a succession chain—and your process for coordinating with local, tribal, regional, state, and federal emergency officials. That means having actual relationships, or at least documented contact procedures, with your local emergency management agency before a disaster happens.

Policies and Procedures

The regulation at §418.113(b) requires policies and procedures based on your emergency plan, risk assessment, and communication plan, reviewed every two years. This is where hospice requirements split depending on whether you're home-based, inpatient, or both.

Requirements for All Hospices

When an emergency disrupts your operations, you need written policies for checking on all on-duty staff to verify their safety and availability, contacting every patient to assess their current service needs, and informing state and local officials about any staff or patients you can't reach. You also need a system that keeps patient records safe, confidential, and accessible during an emergency—if your office takes damage or your cloud system goes down, can you still access your patient records? Your staffing policies must cover how you'll deploy your own staff, how you'd integrate outside healthcare professionals during a surge, how you'll contact off-duty staff, and what happens when staff can't report to work.

Home-Based Hospice

Home-based hospices need procedures to inform state and local emergency officials about patients who need evacuation help. This information—shared in a HIPAA-compliant way—should include the patient's medical condition, psychiatric status, and home environment factors that affect evacuation.

Inpatient Hospice Facilities

Inpatient facilities face the heaviest requirements in this section. Your policies must address subsistence needs under E-0015: food and water provisions for patients and staff, medical and pharmaceutical supplies, and alternate power sources for temperature control, emergency lighting, fire detection and alarm systems, and sewage and waste disposal. You need a patient and staff tracking system under E-0018 that documents where on-duty employees and sheltered patients are at all times during an emergency, including the receiving facility's name and contact information if patients are relocated. You need written evacuation procedures under E-0020 covering needs assessment, staff responsibilities, transportation, evacuation locations, and communication with evacuated patients' families. And you need shelter-in-place procedures under E-0022 for patients and staff who remain in the facility.

The Communication Plan

The regulation at §418.113(c) requires a communication plan, reviewed and updated at least every two years. This is the piece surveyors probe hardest, because it's the piece that fails first in a real event.

You need current contact lists for all employees, entities providing services under arrangement, each patient's attending physician or practitioner, other hospice agencies you might coordinate with for mutual aid, and volunteers. You need contact information for emergency preparedness staff at every level—federal, state, tribal, regional, and local—including your State Survey Agency and local public health department.

You also need both a primary and an alternate method for communicating with your staff and with emergency management agencies. If cell phones are your primary method, your backup needs to work when the towers go down: two-way radios, satellite phones, group messaging platforms that work on Wi-Fi, or a phone tree with landline numbers. Your plan must include a method for sharing essential patient information with other providers to maintain continuity of care, compliant with HIPAA emergency disclosure rules. For hospice, this is critical—your patients' medication regimens, advance directives, and DNR orders must be communicable to any provider who might take over their care. And you need a means of reporting your facility's needs and capabilities to the incident command center or local authority: Can you still serve patients? How many? Do you need supplies?

If your only communication plan is cell phones with no documented backup, that's the gap a surveyor will find.

Training and Testing

The regulation at §418.113(d) requires a training and testing program. Every new employee, contractor, and volunteer needs initial training before they start providing patient care, with refresher training at least every two years and additional training whenever policies or procedures change significantly. You need documentation of all of it—sign-in sheets, content covered, competency demonstrated. Surveyors will ask to see training records, and they'll also ask staff members about the emergency plan to verify that training actually happened. If your staff can't answer basic questions about the plan, the training documentation won't save you.

Exercise requirements depend on your hospice type. Home-based hospices follow the same schedule as home health agencies: at least one exercise per year, alternating between a full-scale community-based or facility-based functional exercise one year and the exercise of your choosing the next. Inpatient hospices have a higher bar—at least two exercises per year, with one being a full-scale or functional exercise annually.

After every exercise, you must analyze your response, document what went well and what didn't, create an improvement plan, and actually update your emergency plan based on what you learned. This After-Action Report/Improvement Plan follows the HSEEP standard that federal reviewers recognize. It's the single document that ties your whole program together, and it's the one surveyors look for most. If your hospice activates its emergency plan during a real disaster, that counts as your exercise for that cycle—but you still need to document what happened and conduct the after-action review. A real emergency doesn't exempt you from learning from it.

What Gets Hospices Cited

The most common EP deficiencies follow a pattern. The plan hasn't been reviewed in more than two years. The risk assessment is either missing entirely or so generic it doesn't reflect the agency's actual geography and patient population. The agency says they ran a drill, but there's no sign-in sheet, no after-action report, and no evidence the plan was updated afterward. Inpatient facilities are missing the extra requirements—no shelter-in-place plan, no subsistence provisions, no patient tracking system. And the communication plan lists cell phones as the only method with no documented alternative.

None of these are complicated to fix. They're easy to let slide when preparedness is one more item on a long list and nobody owns it full time.

Get Survey-Ready This Weekend

The SurgeReady Hospice Ready-Kit includes every template you need—mapped to the E-tags in Appendix Z, organized so a surveyor can find what they're looking for without flipping through a disorganized binder.

Here's a sample of what's inside:

The full kit includes templates for every requirement in this post—risk assessment, emergency plan, home-based and inpatient policies, communication plan, training logs, tabletop exercise scenarios, and the AAR/IP—all organized so a surveyor can flip to exactly what they're checking.

But even without the kit, this guide is your roadmap. Go through it, check what you have against what's required, and close the gaps before the surveyor finds them.

The best time to fix your EP documentation was last year. The second best time is this weekend.

This post is educational and does not constitute legal or compliance advice. Consult your compliance team or legal counsel for guidance specific to your facility.

SurgeReady brings the same emergency preparedness tools large hospital systems use to community-based healthcare organizations. Get in touch.