What you actually get
This is the artifact the survey procedure is asking for when it says evidence of the review. Every number on the emergency communication plan, dialed on a schedule, timestamped, with the failures named rather than averaged away.
Emergency Contact Roster Attestation
| Plan category | Contact | Time | Result | To answer | Status |
|---|---|---|---|---|---|
| Staff | Administrator, after-hours cell | 02:14 | Answered by administrator | 3 rings · 9s | PASS |
| Staff | Director of Nursing, after-hours cell | 02:16 | Answered by DON | 2 rings · 7s | PASS |
| Staff | Maintenance on-call | 02:18 | Voicemail, mailbox full | 8 rings | FAIL |
| Entities under arrangement | Contract pharmacy, 24-hour line | 02:21 | Answered by pharmacist | 4 rings · 14s | PASS |
| Entities under arrangement | Clinical laboratory, critical value line | 02:24 | Answered by tech | 2 rings · 6s | PASS |
| Entities under arrangement | Medical transport dispatch | 02:27 | Number disconnected | SIT tone | FAIL |
| Residents' physicians | Attending physician group, answering service | 02:31 | Answered by service | 5 rings · 21s | PASS |
| Residents' physicians | Covering physician, direct | 02:34 | Answered by covering MD | 6 rings · 27s | REVIEW |
| Other LTC facilities | Evacuation partner A, administrator line | 02:38 | Answered by night supervisor | 4 rings · 12s | PASS |
| Other LTC facilities | Evacuation partner B, main line | 02:41 | Rang out, no voicemail | 12 rings | FAIL |
| Volunteers | Volunteer coordinator | 02:44 | Answered by coordinator | 3 rings · 11s | PASS |
| Emergency preparedness officials | County emergency management, 24-hour | 02:47 | Answered by duty officer | 2 rings · 8s | PASS |
| State Licensing and Certification Agency | State survey agency, main line | 02:50 | Recorded business-hours message | n/a | PASS |
| State LTC Ombudsman | State ombudsman program | 02:52 | Recorded business-hours message | n/a | PASS |
Attestation
ResponseProof placed the calls listed above to the contact numbers supplied from this facility’s emergency preparedness communication plan. Each attempt was recorded and scored. Results are reported exactly as observed, including failures.
Three numbers did not reach a person: maintenance on-call (mailbox full), medical transport dispatch (disconnected), and evacuation partner B (rang out, no voicemail). One is flagged for review: the covering physician answered at 27 seconds, outside this facility’s own 20-second standard.
Why this format
The communication plan must be reviewed on a fixed cycle, and Appendix Z tells surveyors to verify that review “by asking to see evidence of the review.” A list of numbers with a date on it does not show anyone checked them. A dated log of actual call attempts, including the ones that failed, does.
The failures are the useful part. A report where everything passes tells you nothing you did not already assume. Full requirement at 42 CFR § 483.73(c), and the identical duty across 16 provider types.
Run this against your own roster
Send the contact list from your emergency preparedness plan and we will produce this report for it.
Sample document for illustration. ResponseProof is a quality-assurance and evidence tool, not legal advice and not a guarantee of survey outcomes.