The hospital provides orientation, education, and training to their staff.

(1)

Staff participate in ongoing education and training to maintain or increase their competency and, as needed, when staff responsibilities change. Staff participation is documented.

(2)

Applicable staff, as identified by the hospital, are trained annually on the protocols and provisions implemented for emergency services readiness. Note 1: The hospital must document in staff personnel records that the annual training was successfully completed. Note 2: For hospitals that use Joint Commission accreditation for deemed status purposes: Protocols and provisions implemented for emergency services readiness are pursuant to 42 CFR 482.55(c). For 482.55(c), refer to https://www.ecfr.gov/current/title-42/part-482/section-482.55#p-482.55(c).

(3)

For hospitals that use Joint Commission accreditation for deemed status purposes: The governing body identifies and documents which staff must complete the annual emergency services readiness protocols and provisions training.

(4)

The hospital is able to demonstrate staff knowledge on the topics implemented for emergency services readiness protocols and provisions.

(5)

The hospital uses findings from its quality assessment and performance improvement (QAPI) program to inform staff training needs and any additions, revisions, or updates to training topics on an ongoing basis. Note: For hospitals that use Joint Commission accreditation for deemed status purposes: Quality assessment and performance improvement findings are used as required at 42 CFR 482.21. For 482.21, refer to https://www.ecfr.gov/current/title-42/section-482.21.