Before we begin. Summary on CMS rule for minimum Emergency Preparedness requirements

Transcription

1 Summary on CMS rule for minimum Emergency Preparedness requirements Tina T. Wright, Program Manager Emergency Management & Public Information Southeastern MA Regional CHC Representative January 2017 Before we begin Housekeeping Please silence your cell phones Review of evacuation procedures Tina T. Wright, MLCHC 1

2 Today s objectives: Understand the requirements of the new Center for Medicaid and Medicare Services (CMS) rule which establishes minimum requirements for emergency preparedness in healthcare. Be able evaluate your facility s ability to meet these requirements within the timeline 3 CMS rule for minimum EP requirements REGULATORY REQUIREMENT as a Conditions of Participation (CoP) Includes 17 provider and supplier types Must be in compliance to participate in Medicare and Medicaid Four focus areas: 1. Emergency plan 2. Policies and procedures 3. Communications plan 4. Training and testing program (including 2 annual exercises) All-hazards Risk Assessment tied to each focus area Tina T. Wright, MLCHC 2

3 Why this new CMS rule? Conditions of Participation (CoPs) and Conditions for Coverage (CfCs) are health and safety regulations which must be met by Medicare and Medicaid-participating providers and suppliers. They serve to protect all individuals receiving services from those organizations Creates commonalities between and amongst healthcare facilities Aligns well with requirements by the Joint Commission, especially for hospitals Language is heavy with Coalition integration CMS rule, cont. Providers and Supplies: Hospitals Critical Access Hospitals Long-Term Care Facilities, Skilled Nursing Facilities, and Nursing Facilities Religious Nonmedical Health Care Institutions Ambulatory Surgical Centers Hospices Psychiatric Residential Treatment Facilities Programs of All- Inclusive Care for the Elderly Transplant Centers Intermediate Care Facilities for Individuals with Intellectual Disabilities Home Health Agencies Comprehensive Outpatient Rehabilitation Facilities Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services Community Mental Health Centers Organ Procurement Organizations Rural Health Clinics and Federally Qualified Health Centers End-Stage Renal Disease Facilities Tina T. Wright, MLCHC 3

4 CMS rule, cont. Timeline Published to the Federal Registry on Sept. 16, 2016 In effect after 60 days from date of public, Nov. 16, 2016 Have 1 year from effective date to implement, by Nov. 15, Tina T. Wright, MLCHC 4

5 Risk Assessment Must be all-hazards risk assessment, such as a Hazard Vulnerability Analysis (HVA) 2-fold assessment facility and community based Annual review and maintenance Emergency Preparedness Plan Must be based on the results of the Risk Assessment Address the needs of the your patient populations Address the types of services the facility can provide in an emergency Must include business continuity best practices, such as delegation of authority and succession plans Tina T. Wright, MLCHC 5

6 Policies & Procedures Based on the risk assessment, EP plan, and communications plan Are to include a system for tracking on-duty staff and sheltered patients during an emergency Medical documentation sharing if patients transfer to alternate facility, compliant with federal and state privacy laws Include policies for Volunteers Communications Plan Refers back to EP plan; must comply with Federal and State laws Facilitate both internal (staff & patients) and external (federal, state, local agencies) communications Must include a method for sharing information and medical documentation with other healthcare providers to ensure continuity of care for patients Tina T. Wright, MLCHC 6

7 Communications Plan, cont. Communicate to the local incident command center of an emergency the facility s ability to provide assistance before, during and after the event Alternate means of communication in case of interruption in phone service Training and Testing Program Review current training programs, compare to risk assessment, EP plan, communications plan, and policies and procedures Provide initial training to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with expected roles Staff must be able to demonstrate knowledge; documentation of staff training Tina T. Wright, MLCHC 7

8 Full-scale Exercise 2 exercises annually, 1 being full-scale while the other is at the facility s discretion If full-scale is not an option, a facility-based exercise, as long as it is documented, will meet the requirement An actual emergency that requires the activation of the emergency plan, as long as it is documented, meets the full-scale exercise requirement for 1 year after the actual event Analyze response to and maintain documentation of drills, table top exercises, and emergency events Emergency Preparedness Exercises: Level of Complexity Source: Federal Emergency Management Agency (FEMA) Tina T. Wright, MLCHC 8

9 Homeland Security Exercise Evaluation Program (HSEEP) Definitions of Exercises Discussion-based exercises familiarize participants with current plans, policies, agreements and procedures, or may be used to develop new plans, policies, agreements, and procedures. Types of discussion-based exercises include: Seminar: A seminar is an informal discussion, designed to orient participants to new or updated plans, policies, or procedures (e.g., a seminar to review a new Evacuation Standard Operating Procedure). Workshop: A workshop resembles a seminar, but is employed to build specific products, such as a draft plan or policy (e.g., a Training and Exercise Plan Workshop is used to develop a Multi-year Training and Exercise Plan). Tabletop Exercise (TTX): A tabletop exercise involves key personnel discussing simulated scenarios in an informal setting. TTXs can be used to assess plans, policies, and procedures. Games: A game is a simulation of operations that often involves two or more teams, usually in a competitive environment, using rules, data, and procedure designed to depict an actual or assumed real-life situation. Homeland Security Exercise Evaluation Program (HSEEP) Definitions of Exercises Operations-based Exercises validate plans, policies, agreements and procedures, clarify roles and responsibilities, and identify resource gaps in an operational environment. Types of operations-based Exercises include: Drill: A drill is a coordinated, supervised activity usually employed to test a single, specific operation or function within a single entity (e.g., a fire department conducts a decontamination drill). Functional Exercise (FE): A functional exercise examines and/or validates the coordination, command, and control between various multi-agency coordination centers (e.g., emergency operation center, joint field office, etc.). A functional exercise does not involve any boots on the ground (i.e., first responders or emergency officials responding to an incident in real time). Full-Scale Exercises (FSE): A full-scale exercise is a multi-agency, multijurisdictional, multi-discipline exercise involving functional (e.g., joint field office, emergency operation centers, etc.) and boots on the ground response (e.g., firefighters decontaminating mock victims) Tina T. Wright, MLCHC 9

10 Integrated health system option Allows a separate healthcare facility that operates within a healthcare system to elect to be a part of that system's unified emergency preparedness program. Must demonstrate that each separately facility actively participates Each facility must demonstrate program implementation and compliance with requirements at the facility level CMS rule, cont. ASPR TRACIE resources: ov/documents/cms-eprule-resources-at-yourfingertips.pdf CMS Surveyors Interpretive Guidance is due to be published in the Spring 2017 but DO NOT WAIT Tina T. Wright, MLCHC 10

11 Failure to meet these minimum requirements will result in termination of participation in CMS programs As per 10/05/16 call with CMS. In Dec 2016 at the National Healthcare Coalition Conference, CMS staff stated that normal procedures for implementing plans to meet compliance would be acceptable. Links: CMS Rule for Minimum Emergency Preparedness Requirements - Certification/SurveyCertEmergPrep/Emergency-Prep-Rule.html 10/5 call on the rule recording and slides now available online - Education/Outreach/NPC/National-Provider-Calls-and-Events- Items/ Emergency- Preparedness.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=desc ending Assistant Secretary for Preparedness and Response (ASPR) Technical Resources Assistance Center Information Exchange (TRACIE) webpage on the rule Tina T. Wright, MLCHC 11

12 Thank you! Questions? Contact Tina Wright, Tina T. Wright, MLCHC 12