The surveyor cadre is not particularly knowledgeable about the practical application (and implications, for that matter) of federal level emergency management activities.
There is a broad-based Joint Commission requirement for organizations to comply with applicable local, state, and federal laws and regulations, but even the National Incident Management System and Hospital Incident Command System only truly become “requirements” when we sip from the nectar of the HRSA grants.
Rather, Joint Commission surveyors will expect evidence of some competencies relative to incident command roles and responsibilities, and they will expect staff to be able to articulate their role in the response plan.
They will also expect whichever group is in attendance for the emergency management interview session can speak to the organization’s preparedness and response capabilities, and may even present you with a scenario to role play. There have been instances in which they’ve traced disaster scenarios out into the organization. I’ve heard horror stories of surveyors making organizations stand up there emergency operations center, but I’ve never actually spoken to someone who’s had to deal with that outrageousness.
The important thing is the focus on your hazard vulnerability analysis, with the operative word being “your” — this is all about what happens at your hospital, nowhere else. Determine how you ensure that folks are sufficiently competent to respond appropriately to an emergency, which is where you make good use of the annual evaluation process. Education and competency ought to be in the mix when you evaluate the program, so that’s where you make your case.