02/05/2026

You Asked... We Answered

You Asked: What form is required to be completed after conducting a full-scale exercise of the emergency plan?  

We Answered: CMS does not require the use of a specific form following a full-scale emergency preparedness exercise. CMS does provide an optional After Action Report template that may be used; however, facilities may use their own format as long as all requirements outlined in the Emergency Preparedness State Operations Manual (SOM) Appendix Z are met.

CMS provides the following guidance:

Each facility is responsible for documenting their compliance and ensuring that this information is available for review at any time for a period of no less than three (3) years. Facilities should also document the lessons learned following their tabletop and full-scale exercises and real-life emergencies and demonstrate that they have incorporated any necessary improvements in their emergency preparedness program. Facilities may complete an after-action review process to help them develop an actionable after-action report (AAR). The process includes a roundtable discussion that includes leadership, department leaders and critical staff who can identify, and document lessons learned and necessary improvements in an official AAR. The AAR, at a minimum, should determine 1) what was supposed to happen; 2) what occurred; 3) what went well; 4) what the facility can do differently or improve upon; and 5) a plan with timelines for incorporating necessary improvement. Lastly, facilities that are a part of a healthcare system can elect to participate in their system’s integrated and unified emergency preparedness program and exercises. However, those that do will still be responsible for documenting and demonstrating their individual facility’s compliance with the exercise and training requirements.