CMS EP Rules Roll Out. One Year Later 9/5/2018. Presented by: Faculty

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1 Presented by: Faculty 2018 IHCA Annual Convention Emergency Preparedness Are You Prepared?! Joy L. Ward, RN, BSN, RAC-CT, LNHA, MBA President, Ward & Associates Health Services, Inc. and Joe Ramos, RN, BSN Emergency Response Coordinator Office of Preparedness and Response Illinois Department of Public Health The New Emergency Preparedness Rules Are you Go For Launch? Summary: The New Final Rule on Emergency Preparedness was implemented on November 15, J. Ramos will present Health Care Coalitions in Illinois and reinforce the need for collaboration to establish a more coordinated and defined response to disasters and be prepared J. Ward will present the Providers Perspective on this new rule CMS EP Rules Roll Out Objectives: By the end of this session each participant should be able to: Gain increased knowledge of the 4 Components of the New CMS Emergency Preparedness Rules Determine gaps in their procedures they still need to implement in their emergency plan to meet the new guidelines and survive the new survey process Understand who they need to collaborate with to ensure they have operationalized their plan s readiness for all emergencies One Year Later 4 1

2 Goal of Presentation Provide awareness on how Health Departments, Coalitions, EMAs have responded to the roll out of the CMS EP Rules and what (new) resources are available discuss the path forward About a year ago in a galaxy far far away 5 6 CMS Roll Out September 2018 Implementation date: November

3 Hospital Preparedness Program HPP Public Health Emergency Preparedness PHEP City Readiness Initiative Grants CRI U.S. Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response (ASPR) / Centers of Disease Control and Prevention The primary sources of federal funding that supports REGIONAL health care preparedness systems Enables the healthcare system to save lives during emergencies that exceed the day to day capacity of health and emergency response systems Health Care Coalitions Evolution of the program (response to 9/11) Facility based purchasing approach Funding Directly to hospitals and health departments Purchased Medical Supplies, disaster equipment, Personal Protective Equipment (PPE), mobile medical units, and pharmaceutical caches Development of Healthcare Coalitions (HCCs) and Healthcare Capabilities Funding focused on the development of mature HCCs Funds were dispersed to promote the Healthcare Capabilities 2017 and Beyond Operationalizing HCCs to have a response role Optimizing membership to expand partnerships Geographic coverage statewide 9 10 LHDs Coalitions & CMS Providers Hospitals HCC EMS Emergency Plan Policies and Procedures Communications Plan Coalition Snapshot Since November 2017 On average how many non hospital CMS Providers attend per Coalition meeting? How many Providers participated in an exercise and training events? Positive outcomes having non hospital CMS providers participate in coalition meetings? EMAs Training and Testing Ongoing issues / challenges having non hospital CMS providers participate in your coalition meetings?

4 HCC Regions On average how many non hospital CMS Providers attend a Coalition meeting? Northern Non Hospital Providers 10 to 25 / +50 Central Non Hospital Providers 4 to 5 Southern Non Hospital Providers 5 to Northern Region CMS Providers participating in an exercise training event? Region 1 Rockford Multiple events 19 CMS Partners at 1 event Region 8 Chicago 9 events / 9 to 35 CMS Partners 1 exercise attendees / 37 organizations (combined) Region 9 Chicago 10 CMS Partners at 1 event Central / Southern Multiple training / exercise events Planning to include CMS partners in future events Positive outcomes having non hospital CMS providers participate in coalition meetings North Networking with various provider types and to hear where a lot of them are standing with the new regs Central / South Gain different perspectives preparedness & provider sides New and different aspect on disaster preparedness challenges that they face

5 Ongoing issues / challenges supporting non hospital CMS providers North / Central / South Majority of our meetings concern grant deliverables Not all are aware of the coalitions Roles and responsibilities of the Coalition in a response are still unclear Roles of RHCC vs Coalition Struggling to figure out how to conduct an exercise making it worthwhile for the non hospital providers. As the coalition grows close to 80 attendees are in a room CMS Partners do not have a bed availability mechanism EMResourse* Check Out EMS Region 11 Non Hospital entities are spread across multiple regions Similar to when hospitals were brought into the NIMS umbrella classes have to be edited to make the content more pertinent. Health Departments and Local EMAs Health Departments and Local EMAs contact us/ Health Departments and Local EMAs

6 Health Departments and Local EMAs Health Departments and Local EMAs emergency preparedness rule/ EMResource Region 11 Non Hospital Providers Health Departments and Local EMAs emergency preparedness resource

7 Health Departments and Local EMAs ASPR TRACIE Technical Resources Assistance Center Information Exchange Emergency Support Function 8 & CSC Catastrophic Incident Response Annex Guidance to support IDPH and Stakeholders involved in emergency responses The Crisis Standards of Care Catastrophic Incident Response Annex focusing on 3 phases of continuum of care for patients Thanks for Participating!! o Conventional Care o Contingency Care o Crisis Care

8 Emergency Preparedness The Providers Perspective! Why on Earth am I doing what I m doing?? People buy into the leader before they buy into the vision. -John Maxwell 9 Months and Counting Are You Go For Launch?! Providers Perspective: Old We ve always done it this way FSM-Manual with Fire Drills, Emergency Drill(s) Tornado, Generator Care, Maintenance, Checks Emergency Disaster Manual on a shelf QAA-No discussion of Emergency Disaster Manual or Annual Updates No Training on Orientation/Annual for All Staff, Contract, Agency, Volunteers 9 Months and Counting Are You Go For Launch?! Providers Perspective: New Provider Feedback I just need the policies Can you assist us with a TTX Exercise to meet the requirement? I have a template from 2013 and policies just gonna change the name, add positions etc and it ll work I ll just use the Hospital s EOP and policies. It s already done I already had my Annual Survey, so I ve got time I notified an outside agency, so I ve met my requirement If you always do what you ve always done, you ll always get what you ve always got. -Henry Ford 8

9 What is Arrested Development? Purpose has to do with one s calling-deciding what business you are in as a person. -Ken Blanchard and Norman Vincent Peale The belief you have been trained the reality You have the Power to Influence your team with new sharpened skills on Building A Successful Strategic Plan for the New Emergency Preparedness Rule focused on safeguarding human resources, maintaining business continuity, and protecting physical resources! Purpose of Emergency Preparedness We never know how far reaching something we may think, say or do today will affect the lives of millions tomorrow. To improve patient or resident safety and increase quality and reliability of care for better outcomes. -B. Palmer Unity is strength when there is teamwork and collaboration, wonderful things can be achieved. -Mattie Stepanek 9

10 Summarizing Emergency Preparedness Nuts and Bolts Background On September 16, 2016, the final rule on Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers was published. This rule affects all 17 provider and supplier types eligible for participation in Medicare. The rule became effective on November15, 2016, and was implemented on November 15, 2017 Need to Know S&C Memo Ref. S&C ALL explaining Guidelines. Strongly encourage ALL to review the IG in full to help make sure their center complies. Emergency Preparedness Introduction: The four main components of the requirements are consistent with the National Preparedness Cycle. The emergency plan, policies and procedures, communication plan and the training and testing program must all be reviewed and updated at least annually. Annual reviews will allow a center to identify gaps and areas for improvement to the center s emergency plan. *Policies and procedures are to be based on the emergency plan, risk assessment, and the communication plan. *The policies and procedures will operationalize a center s emergency plan. *Components of the final requirements focus on an integrated response during a disaster or emergency situation. *Surveyors were provided training on the emergency preparedness requirements. Emergency Preparedness Survey Protocol: Conditions of Participation(CoPs), Conditions for Coverage (CfCs), and conditions for certification and requirements follow the standard survey protocols currently in place for each facility type And will be assessed during initial, revalidation, recertification and complaint surveys as appropriate. Compliance with Emergency Preparedness (EP) requirements will be determined in conjunction with the existing survey process for health and safety compliance surveys or life safety code (LSC) surveys for each provider and supplier type. The survey process in the IG will strongly rely on the written documentation provided by the center and interviews with leadership. 10

11 Emergency Preparedness CONVERSATION STARTER Emergency Preparedness Checklist Survey Protocol: The tags for emergency preparedness will be E Tags and accessible to both health and safety surveyors and LSC Surveyors. State survey agencies will have discretion regarding whether the LSC or health and safety surveyors will conduct the emergency preparedness surveys. Emergency Preparedness Nothing great was ever achieved without enthusiasm. Ralph Waldo Emerson Emergency Preparedness Program: The program encompasses four core elements: Emergency Plan that is based on a Risk Assessment and incorporates an all hazards approach; Policies and Procedures; Communication Plan; and the Training and Testing Program. 11

12 Emergency Plan: Risk Assessment-meant to be comprehensive the healthcare industry has also referred to them as a Hazard Vulnerability Assessments or Analysis (HVA) as a type of risk assessment commonly used in the healthcare industry. Full Scale Exercise- operations-based exercise that typically involves multiple agencies, jurisdictions, and disciplines performing functional (for example joint field office, emergency operation centers, etc.) and integration of operational elements involved in the response, i.e. boots on the ground response Table top Exercise (TTX): involves key personnel discussing simulated scenarios in an informal setting involves senior staff, elected or appointed officials, and other key decision making personnel in a group discussion centered on a hypothetical scenario. Emergency Plan: IG states must be based on and include a documented facilitybased and community-based risk assessment, utilizing an allhazards approach, including missing residents. Must address the special needs of its client population. Centers will need a process for cooperation and collaboration with local, tribal, regional, State, or Federal emergency preparedness officials. Centers will need to include documentation of their efforts to contact officials and of their participation in collaborative and cooperative planning efforts. Emergency Plan: Pg 5 IG, must describe a facility s comprehensive approach to meeting the health, safety, and security needs of their staff and patient population during an emergency or disaster situation. also address how facility would coordinate with other healthcare facilities, as well as whole community during emergency or disaster (natural, man-made, facility). Pg 8 IG Important to Note-annual review of the plan must be documented to include date of review and any updates made to the EP based on review Very Important to Note pg 11 of IG Facilities may rely on a community based risk assessment developed by other entities, such as public health agencies, emergency management agencies, and regional health care coalitions or in conjunction with conducting it s own facility-based assessment. *If this approach is used, facilities are expected to have a copy of the community-based risk assessment and to work with the entity that developed it to ensure that the facility s emergency plan is in alignment. 12

13 Emergency Plan IG pg 13 *Must identify which staff would assume specific roles in another s absence through succession planning and delegations of authority Develop a staffing strategy if staff shortages identified Or develop a surge capacity strategy if facility likely be requested to accept additional patients during an emergency Back up evacuation plans for instances where nearby facilities also affected by emergency Hospices must include contingencies (ESRDs also) Essential Personnel, essential functions, critical resources, vital records and IT data protection, alternate facility ID and location, and financial resources. *Facilities are encouraged to utilize resources from FEMA and Assistant Secretary for Preparedness and Response (ASPR) when developing strategies for ensuing continuity of operations. Policies and Procedures: Final rule outlines provision of subsistence needs for staff and residents, whether they evacuate or shelter in place, will need to include: 1) food, water, medical, and pharmaceutical supplies. 2) Alternate sources of energy to maintain temperatures, emergency lighting, fire detection, extinguishing, and alarm systems, sewage and waste disposal. *Include system to track location of on-duty staff and sheltered residents in center s care during and after emergency..and system for documentation.. *Include arrangements with other LTC facilities and other providers to receive residents in the event of limitations or cessation of operations. Policies and Procedures: Pg 22 of IG Alternate sources of energy depend on the resources available to a facility, such as battery-operated lights, or heating and cooling, in order to meet the needs of a facility during an emergency. Facilities not required to upgrade their electrical systems, but after review of their risk assessment, facilities may find it prudent ( Hint ) to make necessary adjustments to ensure occupants health and safety needs are met, and that facilities maintain safe and sanitary storage areas for provisions. Pg of IG All sources of Energy LTC (e) TAG E-0041 Portable and permanent generator related testing requirements strongly encourage ALL to read. Special Note: portable generators vs permanent generators Policies and Procedures: Pg 23 of IG generators cont d some ESRD facilities have contracted services with companies who maintain portable generators for the facilities off-site. generators are brought in advance. special note Facilities are encouraged to confer with local health department and emergency management officials, as well as healthcare coalitions, where available, to determine types and duration of energy sources that could be available to assist them in providing care to their patient population during an emergency. Environmental Protection Agency (EPA) maintaining necessary services may include but not limited to, access to medical gases; treatment of soiled linens; disposal of bio-hazard material from infectious diseases (sewage and waste disposal) 13

14 Policies and Procedures: Designated transportation services most appropriate for needs of their patient population Criteria for determining which patients and staff would be sheltered in place Pg 27 of IG...recommend facility with electronic database consider backing up computer system with secondary source, such as hard copy documentation Pg 35 of IG method for contacting off-duty staff during an emergency and procedures to address other contingencies, i.e utilizing staff from other facilities and state or federally-designated health professionals. Pg 36 of IG policies and procedures which include pre-arranged transfer agreements Pg 38 of IG.. Polices and procedures that describe their role in providing care at alternate care sites during emergencies 1135 Waiver may be granted to waive licensure for physicians..need policies and procedures which outline responsibilities during duration of emergency Policies and Procedures: Important to Note IG pg 19 We are not specifying where the facility must have the emergency preparedness policies and procedures. A facility may choose whether to incorporate the emergency policies and procedures within their emergency plan or to be part of the facility s Standard Operating Procedures or Operating Manual. However the facility must be able to demonstrate compliance upon survey, therefore we recommend that facilities have a central place to house the emergency preparedness program documents (to include all polices and procedures) to facilitate review. Communication Plan: Must comply with Federal, state, and local laws. Must include name and contact information for nine key groups including volunteers Need primary and alternate system for communicating with center staff and Federal, State, tribal, regional, or local emergency management agencies. Pg 41 of IG facilities must have a written emergency plan that contains how facility coordinates patient care within the facility, across healthcare providers, and with state and local health departments. HIPAA requirements are not suspended during a national or pubic health emergency however HIPAA Privacy Regulations at 45 CFR (b)(4), Use and disclosures for disaster relief purposes Communication Plan: Important to Note Plan should include procedure of when and how alternate communication methods are used, and who uses them. Ensure selected alternative means of communication is compatible with communication systems of other facilities, agencies and state and local official it plans to communicate with during emergencies. EXAMPLE, if state X local emergency officials use the SHAred RESources (SHARES) High Frequency (HF) Radio program and facility Y is trying to communicate with RACES, it may be prudent ( Hint ) to consider these two alternate communication systems can communicate on same frequencies. Pg. 48 Includes List of what patient information and medical documentation should be shared with other health care providers! 14

15 Communication Plan: As defined by Federal Emergency Management Administration (FEMA) an Incident Command System (ICS) is a management system designed to enable effective and efficient domestic incident management by integrating a combination of facilities equipment, personnel, procedures, and communications operating within a common organizational structure. Incident Command Center to mean Emergency Operations Center or Incident Command Post Communication Plan: Very Important Note for providers- LTC facilities and ICF/IIDs are required to share emergency preparedness plans and policies with family members and resident representatives or client representatives, respectively. We ( Hint ) recommend that facilities provide a quick Fact Sheet or informational brochure to the family members and resident or client representatives which may highlight the major sections of the emergency plan and polices and procedures deemed appropriate by facility. Pg 51 of IG Other options include providing instructions on how to contact facility in the event of an emergency on the public website or to include the information as part of the facility s check-in (Admission Agreement) procedures **Note Survey Process : Facility may provide this information to the surveyor during survey to demonstrate compliance. Training and Testing: Testing is the concept in which training is operationalized and the facility is able to evaluate the effectiveness of the training as well as the overall emergency preparedness program. Testing includes conducting drills and/or exercises to test the emergency plan to identify gaps and areas of improvement. Centers will need to conduct initial training in emergency preparedness policies and procedures to all existing staff, contract staff, and volunteers. Training must be documented and staff must be able to demonstrate knowledge of the emergency preparedness procedures. Again Survey Process -Orientation, Annual Training, needs to align with emergency plan and risk assessment. Then complete an After Action Report (AAR) during last emergency drill and incorporate into annual review of plan. Training and Testing: Important Survey Procedures (pg. 56 of IG) Ask for copies of the facility s initial emergency preparedness training and annual emergency preparedness training offerings. Interview various staff and ask questions regarding the facility s initial and annual training course, to verify knowledge of emergency procedures. Review a sample of staff training files to verify staff have received initial and annual emergency preparedness training. *Note: Ensure copies of CPR certifications for all patient care staff are on file. 15

16 Training and Testing Training and Testing: 2. Testing for LTC Facilities at (d) Section (d)(2)(i) through (iii) Will require LTC facilities to do all of the following: (i)participate in a full-scale exercise that is community-based or when a communitybased exercise is not accessible, an individual, facility-based. If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in a community based or individual, facility-based full scale exercise for a 1 year following onset of the actual event. (ii) Conduct an additional exercise that may include, but is not limited to the following (A) A second full-scale exercise that is community-based or individual, facility-based. (B) A tabletop exercise that includes a group discussion led by a facilitator using a narrated, clinically-relevant emergency scenario, and a set of problem statements. Directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility s] emergency plan, as needed. Each facility is responsible for documenting their compliance and ensuring that this information is available for review at any time for a period of no less than (3) years. A full-scale exercise is also an operations-based exercise that typically involves multiple agencies, jurisdictions, and disciplines performing functional or operational elements. Important Note: Testing the Emergency Operations Plan- Facilities must focus on testing the Emergency Operations Plan (EOP) through exercises. The Homeland Security Exercise and Evaluation Program (HSEEP), which was developed by Federal Emergency Management Agency (FEMA) is a proven process. The HSEEP concept was developed for both the public and private sector as a process for designing, developing, conducting and evaluating exercises that test the EOP. JCAR Administrative Code Section Coordination with Local Authorities Annual forwarding of copies of all disaster policies and plans required under this Section to the local health authority and local emergency management agency having jurisdiction Including: Emergency water supply agreements Description of emergency electrical power, including the services connected to the source and also must inform at any time that the emergency source of power or services connected to the source are changed Participating with local emergency planning activities ftp:// JCAR Administrative Code Section

17 9 Months and Counting Are You Go For Launch?! Providers Perspective: New Emergency preparedness requirements and survey process updates Emergency Preparedness (EP) survey is being completed during the annual LTC survey. There is a separate 2567 with E-tags. Life Safety Code (LSC) surveyors are focusing on E-tags E15, E22, and E41. The health and safety surveyors are reviewing all the other E-tags. With regards to the health and safety survey, the initial EP survey is focusing on the bigger picture that facilities have an emergency plan, policies and procedures to implement the plan, have a communication plan and that they are training staff about the plan and conducting (2) required exercises. Important to Note -Future surveys will go into more depth and substance so do not be complacent. 9 Months and Counting Are You Go For Launch?! Providers Perspective: New Emergency preparedness requirements and survey process updates (cont d) Most of the E-tag deficiencies written so far are in the tags done by the LSC surveyors-e15, E22 and E41 ( Hint ) Do not be complacent! Generator to be able to supply: Maintain temps Sanitary storage of provisions Emergency lighting Fire detection, extinguishing and alarm systems Sewage and waste disposal 96 hour fuel supply for new generators in seismic zones Integrity is doing the right thing, even when no one is watching. -C.S.Lewis Emergency Preparedness Tool Kit Need to Know S&C Memo (S&C ALL) explaining Guidelines JCAR Administrative Code Section Review of Emergency Preparedness Tools Helpful Links Online copy of IG CMS Website CMS Emergency Preparedness Rule will bring up key websites AHCA Summary of IG HHS ASPR The Technical Resources, Assistance Center, and Information Exchange TRACIE website CMS Emergency Preparedness Training Online Course Go to Integrated Surveyor Training Website Click on I am a Provider Leadership This means that it is vital for organizations and their leadership to walk their talk. They must make every effort to become living symbols of their organization s value system. Just remember though, this is an ongoing process-a journey without a finish line. The Heart of a Leader 17

18 Questions?? #Collaboration#Leadership#Team Joe Ramos, RN, BSN Emergency Response Coordinator Office of Preparedness and Response Illinois Department of Public Health 122 S. Michigan Avenue, 7 th Floor Chicago, Illinois Office: Mobile: Joe.Ramos@Illinois.gov Joy L. Ward, RN, BSN, RAC-CT, LNHA, MBA President/CEO Ward & Associates Health Services, Inc. joy@wardhealthservices.com Phone: (630) If everyone is moving forward together, then success takes care of itself. - Henry Ford 2018 IHCA Annual Convention Emergency Preparedness Copyright 2018 Ward & Associates Health Services, Inc., All Rights Reserved. Thank you! 18