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1Clear out junk files and repair common Windows errors2Fix the driver behind crashes, sound loss and screen glitches3Repair Windows errors before they cause bigger problemsTo fix gaps found during an emergency drill, turn each observation into a specific, risk-prioritized corrective action, assign an owner and due date, track it to completion, and retest the changed capability. The debrief is the start of that cycle—not proof that the problem is fixed.
Start with the exercise objective and the intended procedure
Before deciding what to change, establish what the drill was designed to test and what the facility’s plan said should happen. Set evaluation areas before an exercise, and base scenarios on hazards identified in the facility’s risk assessment. ASPR recommends realistic scenarios that test the plan rather than merely rehearse familiar steps. See ASPR TRACIE’s healthcare coalition exercise guidance.
The relevant test depends on the facility and hazard. CMS survey guidance gives examples such as choosing evacuation or shelter-in-place during flooding, accounting for people with access and functional needs, identifying patients dependent on electricity-powered life-support equipment, locating staff, assessing patient acuity, coordinating with local agencies, and maintaining continuity-of-care information. These are examples to select from—not a checklist that applies identically to every facility. Consult the facility’s risk assessment and applicable provider-specific requirements.
Collect evidence while the details are fresh
Build the after-action report (AAR) from multiple perspectives and records, not memory alone. Gather evaluator observations, participant and role-player feedback, and relevant exercise materials such as notification messages or incident-command forms. Include the staff and partner organizations that took part.
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Hold a prompt post-exercise “hot wash” to capture immediate successes and challenges. Then schedule a more structured AAR discussion after participants have had time to recover and the management team can prepare. ASPR’s healthcare coalition exercise resources describe evaluation planning, feedback, and improvement planning.
Describe each gap in operational terms
For each finding, record what was expected, what was observed, how the difference affected the exercise objective, and what conditions may have contributed. Document strengths as well as gaps. CMS says an AAR should address expected and actual performance, what went well, what needs improvement, and a plan with timelines. Evaluate systems, processes, and procedures rather than grading individual workers.
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For example, “the receiving department did not get the transfer update” identifies an observable result. “Communication failed” is too broad to guide a fix. Investigate whether the cause was an outdated contact list, unclear role ownership, an unavailable channel, or a procedure that had not been practiced. Treat the first observation as a clue to investigate, not a verdict about the cause.
Write corrective actions that can be completed and checked
Translate each finding into a defined change. A useful action states what will change, who is responsible, when it is due, and what evidence will demonstrate completion. Depending on the finding, actions might include revising a procedure, clarifying who sends a notification, training a shift, updating a contact path, resolving a resource issue, or rehearsing a patient-tracking step.
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Prioritize actions by potential effect on patient and staff safety, continuity, and the facility’s assessed risks. Also consider control and dependencies: a facility may be able to revise its own procedure quickly, while a staffing, funding, vendor, coalition, or local-agency issue may require coordination. Judge proposed actions by whether a later exercise can test them and whether they fit the facility’s patient population and requirements.
ASPR guidance recommends assigning responsibility, reviewing priority, and tracking actions through a continuing corrective-action program. Recommendations can be accepted, revised, declined with a reason, or deferred when they depend on funding; record those decisions deliberately rather than letting findings disappear from view. No single corrective-action deadline is established here for every facility or every finding.
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Track the improvement plan until actions are closed
Keep actions in a living improvement plan, with an owner, due date or milestone, status, and completion evidence. FEMA describes improvement plans as dynamic documents whose corrective actions are continually monitored and implemented as part of improving preparedness. A spreadsheet or the organization’s existing tracking system can serve; the cited guidance does not require a particular commercial platform.
For a starting point, CMS provides a voluntary Health Care Provider After Action Report/Improvement Plan template and instructions. CMS cautions that its templates and checklists are general resources and do not guarantee compliance. Use a template to organize work, not as a substitute for checking the rules and interpretive guidance that apply to the provider category, location, and accreditor.
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Retest the changed capability
When an action is marked complete, verify the capability—not just the paperwork. Re-exercise the changed process or test it during an actual incident when appropriate. Check whether staff followed the updated procedure, whether a handoff or communication reached the intended recipient, and whether the objective was met. If the process still fails, revise the action and keep the finding open for follow-up.
Feed the result into the next cycle of planning, training, exercising, and resource allocation. ASPR’s healthcare coalition preparedness guidance connects exercises, corrective plans, assigned responsibility, tracking, and retesting.
Keep the process connected to CMS requirements and records
For Medicare-participating providers and suppliers, CMS describes four core elements of an emergency preparedness program: risk assessment and planning; policies and procedures; a communication plan; and training and testing. The program includes testing the plan and revising it as needed. CMS’s Health Care Provider Guidance, last modified March 5, 2026, states: “Preparedness includes developing a plan to address how the provider will meet the needs of patients and residents if essential services breakdown as a result of a disaster.”
The CMS State Operations Manual, Appendix Z, Revision 186, issued March 4, 2019, says facilities should document lessons from exercises and real-life emergencies, show that necessary improvements were incorporated, and maintain records available for review for at least three years. Because this is a 2019 manual revision, confirm the current documentation rule and interpretive guidance for your provider type rather than assuming the period applies unchanged to every facility. CMS also notes that preparedness requirements can vary by provider type; a template alone does not establish compliance.
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