The CMS Emergency Management (EM) update is quite extensive and, therefore, covered in a two-part blog series. Continue reading for Part 2. Click here to read Part 1. Please contact us to ask questions or to schedule your consulting needs.

On Friday, June 2, CMS issued document SC-17-29, their State Operations Manual Appendix Z, Emergency Preparedness Interpretive Guidelines. This represents the CMS information on surveying their Emergency Preparedness Conditions of Participation (COPs) that is provided to the CMS surveyors. CMS will use E-tags to score emergency management.

The information in this blog represents summarization of important points of compliance as presented in this interpretive guidance as they apply to hospitals. It approximates the order addressed in the Interpretive Guidelines, but does not strictly follow. In some cases, similar topics are combined in the blog. Other provider types are also addressed in the CMS document, but will not be covered here. The entire CMS document is available here.

MEDICAL DOCUMENTATION:

  • Provide for security of records and availability to support continuity of care
  • Document review:
    • Medical records documentation to maintain availability and provide confidentiality

STAFFING:

  • Document review:
    • Use of staff and volunteers, and other staffing strategies
    • Agreements with other facilities to receive patients

1135 WAIVERS:

  • Examples of compliance that may be waived include:
    • Some existing COPs
    • Physicians’ or others’ licensure requirements in affected states
    • EMTALA
    • HIPAA (not suspended but permits certain use and disclosure)
    • Medicare out-of-network providers
  • Document review:
    • Coordination efforts required when 1135 waivers are requested and granted

COMMUNITY PLANNING:

  • Organizations have flexibility in formulating the community plan
  • Plan must be readily available to leadership and staff
  • Document review:
    • Community plan and annual review
    • Contact information of other facilities of same type
      • May be prudent to have contact information for other type facilities
      • Evidence of data backup
    • Communication Plan: 
      • When, how, and by whom alternate communication methods are used (surveyors may ask to see equipment)
      • Compatibility of communications with other authorities, agencies, and facilities
      • Method of sharing patient information:
        • Patient information sent with evacuated patients per HIPAA requirements, and available for patients sheltering in place
        • Information sent in a timely manner to allow effective continuity of care
        • No delays to assemble records
        • Minimum information includes:
          • Name
          • Age
          • Date of birth
          • Allergies
          • Current medications
          • Diagnosis
          • Reason for admission
          • Blood type
          • Advance directives
          • Emergency contacts
      • Means and process of providing information regarding facility needs and ability to provide assistance:
        • Occupancy reporting
        • Shortage of provisions
        • Assistance with evacuation

TRAINING AND TESTING:

  • Organizations with multiple locations must reflect each facility’s risk assessment
  • Individuals to be trained for awareness of program:
    • Staff
    • Contractors
    • Volunteers
  • Facilities decide on level of training for each staff member
  • Testing: Training is operationalized so facility can evaluate effectiveness of training and overall program
  • Document review:
    • Written training and testing program
      • Meets requirements for evacuation drill and training
      • Aligns with EOP and risk assessment (modified annually for lessons learned)
      • Annual review
    • Training and testing records for all new and existing staff
      • Includes agency nurses and other intermittent staff
      • During orientation or shortly thereafter
      • Contractors and volunteers trained for specific work location and when reassigned
      • Annual training
        • Specific training and methods to demonstrate knowledge
      • Staff training files
  • Staff knowledge:
    • Describe initial and annual training
  • Testing:
    • Annual tabletop exercise
    • Full scale community exercise (or facility based if community exercise is not available)
      • “An operations-based exercise (drill, functional, or full-scale) that assesses a facility’s functional capabilities by simulating a response to an emergency that would impact the facility’s operations and their given community. A full-scale exercise typically involves multiple agencies, jurisdictions, and disciplines performing functional or operational elements.”
  • *MSL NOTE:  The Joint Commission testing requirements are more stringent than those of CMS and the Joint Commission requirements will remain in place.

    • If a facility cannot participate in a community exercise:
      • Document efforts to contact local and state agencies and healthcare coalitions to participate in community exercise
      • Offer participation in the facility exercise to those organizations
      • Demonstrate addressing the risk assessment
      • Includes requirements for patient functional needs and dependency on electrical medical equipment
    • In a community exercise, each facility (including those participating as part of a system) is responsible for documenting their own compliance and lessons learned
      • Available for 3 years
    • After action report (AAR) minimally includes:
      • What was supposed to happen
      • What occurred
      • What went well
      • Opportunities for improvement
    • Actual emergencies can substitute for exercises
  • Document review:
    • Exercise plan
    • After action reports
    • Efforts to identify a full-scale community exercise if no participation
    • Analysis of response and how program updated in response

UTILITIES:

  • Generator(s) located to minimize damage
  • If seismic events are anticipated in risk assessment:
    • 96 hours generator fuel on site or arrangement for delivery
      • Arranged fuel supply sources are not limited by other community demands
  • Document review:
    • Emergency power supply system (EPSS) meets policy and procedure for sheltering in place and evacuation plans
    • If under construction or renovation, plans to relocate EPSS
    • If constructed (new, altered, renovated) between 11/15/16 and 11/15/17, verify that generator located and installed per 2012 edition of NFPA 99 and 2010 edition of NFPA 110
    • Plan to keep generator operational

INTEGRATED HEALTHCARE SYSTEMS:

  • Plans developed to account for each facility’s unique circumstances, patient population, and services offered
  • Each system facility can decide to participate in system plan or develop their own
  • If system plan is used:
    • Updated each time a facility enters or leaves
    • Each facility must actively participate in program development (names in minutes)
    • Each facility must prove effective implementation and demonstrate compliance
    • System must have coordinated community, training, and testing programs to consider each site
      • Each facility maintains individual training and testing records
    • If there is a central system contact, each facility must have information in individual facility plan
      • Seamless communication to EM officials
  • Document review:
    • Facility participation in system plan
    • Documentation of involvement in plan development
    • Copy of integrated plan
  • Leadership knowledge:
    • How system plan is updated based on changes with facilities entering and exiting system

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