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1 Hospice Emergency Preparedness CoP Requirements: Getting Your Hospice Ready Mary St. Pierre, RN, BSN, MGA Regulatory Consultant Before We Get Started Audio is through computer speakers or select Phone on Audio Pane to call in. All attendees are muted. You can ask questions via the GoToWebinar Question Pane throughout the presentation. Handout can be found on the Handout pane in the GotoWebinar Control Panel. On demand video will be made available following the webinar. (c)healthcarefirst 09/2017 1

2 About HEALTHCAREfirst Industry leader in Web based EHR software, coding & billing services, CAHPS survey administration, and advanced analytics for home health and hospice: Founded in 1992 Headquartered in Springfield, MO with additional office in Louisville, KY One of the fastest growing providers of our kind More than 4,000 home health and hospice agencies nationwide We enable our customers to: Make timely and accurate decisions for excellent patient care Adapt quickly to changing requirements and needs Automate agency functions quickly and with high value. EHR Software and Beyond SOFTWARE Web based Agency Management Software for home health & hospice agencies DDE Connectivity All Payer Eligibility Verification Physician Portal OASIS Scrubber SERVICES Coding OASIS Review Billing CMS Submission of Hospice Item Set Data ADVANCED ANALYTICS Executive, Clinical and Financial KPIs Market insights to grow referrals Robust QAPI management & benchmarking Hospice CAHPS & Home Health CAHPS (c)healthcarefirst 09/2017 2

3 Total Solutions Provider Strengthen Profitability Ensure Compliance Improve Quality Objectives Identify emergency preparedness regulations Discuss emergency preparedness surveyor guidance Identify resources (c)healthcarefirst 09/2017 3

4 CMS Goals Hospices establish and maintain an Emergency Preparedness Program Based on detailed assessment Addresses medical and non medical needs Ensures predictable staff behavior Compliant with State, Local, community requirements Updated at least annually Enable government agencies and health care providers to respond in manner that is: Timely Collaborative Organized Effective Federal Hospice Emergency Preparedness Rule Enforcement: November 16, 2017 Surveyors will evaluate for evidence of compliance An all hazards approach required Tailored to each providers and suppliers unique needs Hospices may Create policies that identify situations when unable to operate home hospice services Must meet requirements for hospice operated in patient facilities Note: Rule does not specify/quantity level of detail of the program (c)healthcarefirst 09/2017 4

5 Four Emergency Preparedness Elements Risk Assessment and Planning Policies and Procedures Communication Plan Training and Testing Hospice Emergency Preparedness: 42CFR E 0001 Establish Emergency Preparedness Program Compliant with all applicable Federal, State, and Local requirement Can be verified by administrative staff Written evidence Comprehensive approach to health, safety, security needs staff and patient needs Means to coordinates with other healthcare facilities, community Contains all required elements Is updated annually (c)healthcarefirst 09/2017 5

6 Emergency Preparedness Plan E 0004 Emergency Preparedness Plan Copy can be produced Documented evidence Annual review Update Evidence of how the hazard risk assessment was conducted Evidence of: Collaboration with local emergency preparedness officials Likely durations of interruptions identified Arrangements to ameliorate interruptions Plan: Risk Assessment E 0006: Emergency Plan based on risk assessment Written evidence: facility based, community based risk assessment All hazards approach Natural Man made Facility based Community based In home Examples: equipment and utility failures, interruptions in communication, essential resources, travel, supplies Note: Assessment may be a community assessment developed by other entities as long as a copy available and Hospice emergency plan in alignment (c)healthcarefirst 09/2017 6

7 Plan: Risk Assessment Potential Hazard Examples Pandemics Hurricanes Tornados Fires Earthquakes Power outages Chemical Spills Terrorist attacks Etc. (e.g. floods, bridge collapses, nuclear accidents) Plan: Risk Assessment E 0006: Emergency Plan based on risk assessment actions to be taken: Determine facility s hazard vulnerabilities Consider location, service area Identify communication issues, evacuation routes, fuel needs, etc. Consider financial and security needs Identify other providers/suppliers with which to collaborate Optional for Hospice at home: consider meeting staff needs (e.g. transportation, sheltering staff/family members) (c)healthcarefirst 09/2017 7

8 Plan: Risk Assessment E 0006: Emergency Plan based on risk assessment Strategies for addressing emergency events identified by the risk assessment Patient population Types of services Ability to provide services Written individual plans for each patient as part of the comprehensive patient assessment Includes potential in home disasters patient may face (e.g. fire hazards, flooding, and tornados) Information as to how and when a patient is to contact local emergency officials has been determined Integrated planning with state and local entities has been undertaken Plan: Patient Population & Services E 0007: Plan includes Identification of needs/characteristics of patient population Patients needs if service interruptions Strategies to address needs vulnerable patients Continuity of operations Plans/Procedures to continue operations (if/when) Identification of inpatient/outpatient Types of services to provide (accepting new patients, surge needs) Delegation of authority/succession plan Staff and specific roles Follow up on duty staff, patients Critical resources Vital records and IT data protection Financial resources Alternate facilities (referring patients) (c)healthcarefirst 09/2017 8

9 Plan: Patient Population & Services E 0007: Plan includes Determination of patients at risk during an emergency event Require additional response assistance maintaining Independence Mobility Communication Transportation Supervision, and medical care Are of diverse cultures and racial and ethnic backgrounds Limited English proficiency Chronic medical disorders Pharmacological dependency Plan: Patient Population & Services E 0007: Plan includes Other emergency staffing strategies have been addressed Integration with State or Federally designated health care professionals Resources from various agencies (FEMA, ASPR, etc.) (c)healthcarefirst 09/2017 9

10 Plan: Collaboration E 0009: Plan Demonstrates Collaboration Processes with existing local, tribal, regional, State, and Federal resources was established Efforts to contact such officials are documented Procedures are in place to officials about patients in need of evacuation Procedures in place to identify/inform officials of any on duty staff/patients unable to be contact Policies & Procedures E 0013: Plan includes policies and procedures Written emergency preparedness policies and procedures created/accessible Developed based on based risk assessment Include details of the communication plan Address training and testing Evidence that reviewed/updated annually (c)healthcarefirst 09/

11 Policies & Procedures E0015: Inpatient facility resources: Food, water, medical and pharmaceutical supplies needs Alternate sources of energy to Maintain temperatures Safe and sanitary storage Emergency lighting Fire detection, extinguishing, and alarm systems are operational Sewage and waste disposal are planned for Note: Generators are not required if other appropriate alternate energy sources are identified May consider role/needs of volunteers, visitors, assisters, shelter seekers Policies & Procedures E0016: Follow up with on duty staff and patients Information available regarding needed patient services Mechanism track patients and staff contact information Procedures to follow up with on duty staff and patients Access to information on duty staff and patients unable to be contacted Processes for notification of State and local officials of on duty staff or patients unable to contact (c)healthcarefirst 09/

12 Policies & Procedures E 0018: Inpatient facility tracking location of on duty staff and sheltered patients in the facility s care Tracking system for on duty staff and sheltered patients in place Safe evacuation from the hospice has been established Evacuation sites are identified Care and treatment needs of evacuees are addressed Staff responsibilities are defined Transportation is planned Primary and alternate means of communication with external sources are determined Evacuation locations are identified A system for documenting the specific name and location of the receiving facility/ location identified Policies & Procedures E 0019: Procedures to inform State and Local emergency preparedness officials About patients in need of evacuation from their residences Considers patient choice HIPAA compliant Includes clinical care needed for the patients Clinical information includes/not limited to: level of mobility, medications, equipment required/portability, special need (e.g. communication challenges, language barriers, intellectual disabilities, special dietary needs, etc.) In compliance with State/local laws, community practices (c)healthcarefirst 09/

13 Policies & Procedures E0020: Inpatient facility related to care and treatment needs of evacuees A triaging system for evacuation created Staff responsibilities addressed Transportation needs planned Evacuation locations identified Primary and alternate means of communication with external sources of assistance identified Policies & Procedures E0022: Inpatient facility shelter in place Consideration to building(s) to survive a disaster Step identified prior to an emergency to facilitate sheltering in place or transferring Criteria established to identify which staff/patients would be sheltered in place Criteria is aligned with the Hospice assessment and type of disaster Appropriate sites for transfer or discharge are identified Policies based on the types of potential patients, staff, volunteers and visitors (c)healthcarefirst 09/

14 Policies & Procedures: Medical Record Documentation E 0023: Policies and procedures for system of medical documentation System preserves patient information Protects confidentiality of patient information Secures and maintains availability of records. Policies & Procedures E 0025: Inpatient Hospice arrangements with other facilities and providers to receive patients Transfer arrangements with other facilities Documented arrangements include written agreements/ contracted agreements Agreements ensure maintained continuity of care (c)healthcarefirst 09/

15 Policies & Procedures E 0026: The role of the Hospice under a waiver declared by the Secretary Describe hospice role in providing care at alternate sites Address the Hospice s role in emergencies where the President declares a major disaster or emergency Address what coordination efforts required during a declared emergency Address emergency situations in which a declaration was not made and where an 1135 waiver may not be applicable (e.g. during a disaster affecting the single facility) Communication Plan E 0029: A Communication Plan Is written and available Complies with Federal, State, local laws Considers optional methods of communication (e.g. satellite phones, radios, short wave radios) Addresses coordination of patient care within and across providers Address coordination of patient care with State and local public health departments Reviewed and updated annually Note: Hospices in rural or remote areas (c)healthcarefirst 09/

16 Communication Plan: Content E 0030: The Communication Plan content Includes names and contact information for Staff, Patients, Physicians, Other facilities identified as resource Contact information is available and updated throughout the year Maintained capability to reproduce contact lists/access during emergencies Electronic data storage: data back up with hard copies or demonstrate capability to reproduce/access contact lists Communication Plan: Content E 0031: The Communication Plan content Contact information for Federal, State, Tribal, Regional, and Local emergency preparedness staff Other sources of assistance Evidence that reviewed and updated at least annually Is readily available Is accessible to leadership If electronic data storage Data back up with hard copies, or Demonstrated capability to reproduce contact lists/access during emergencies (c)healthcarefirst 09/

17 Communication Plan: Means of Communication E 0032: The Communication Plan addresses Primary and alternate means for communicating with the Staff, Federal, State, Tribal, Regional, and Local emergency management agencies Alternate means of communication have been considered and addressed (pagers, cellular telephones, radio transceivers, NOAA Weather Radio and Amateur Radio Operators (HAM Radio) systems, satellite telephone communications systems and should include issues with cellular phones, State and local emergency use of communication systems and short wave radio. Equipment or systems listed can be verified Reviewed and updated at least annually Communication Plan: Patient Data E 0033: The Communication Plan includes Written policies and procedures to ensure Means to provide information about the general condition/location of patients Methods for sharing medical information with other health providers Evidence that system would Ensure timely, accurate release of information and available to family members Be HIPAA compliant (in emergencies)requirements are met in consideration of disclosure exceptions during emergencies Patients are given the opportunity to agree to or to object to disclosure (c)healthcarefirst 09/

18 Communication Plan: Needs & Capabilities E0034: Inpatient Hospice information Plans to communicate with jurisdiction of authority Needs Capacity Occupancy (patient census, high tech needs, frequency of visits) Assistance capabilities Other considerations (road conditions, access to fuel, assistance with evacuation and transfers, etc.) Training & Testing E0036: Develop and maintain written emergency preparedness training and testing program Based on the emergency plan and the program Includes education in plan content Reflect risks identified in assessment Identifies how hospice will communicate facility closure Provided to staff, contractors, and facility volunteers Testing evaluates effectiveness of the training/emergency preparedness program Includes conduct of drills and/or exercises Tests plan to identify gaps and areas for improvement Tests patient tracking systems Location specific in multiple location agencies Documented evidence reviewed and updated annually (c)healthcarefirst 09/

19 Training Program E 0037: Training Program includes Initial role consistent training In policies and procedures To all new and existing staff, contractors, volunteers And, at least annually Training files verify all training content, methods Annual training modified each year, as appropriate Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff) Special emphasis placed on carrying out the procedures necessary to protect patients and others. Testing E 0039 Testing: Conduct exercises to test the emergency plan at least annually 1) Participate in a full scale exercise that is community based or when a community based exercise is not accessible, an individual, facility based exercise Exercise demonstrates risks identified in its risk assessment Exercise includes unannounced staff drills using the emergency procedures NOTE: If actual natural or man made emergency/plan activation exempt for 1 year 2) Conduct an additional exercise that may include, but is not limited to the following: A second full scale exercise that is community based or individual, facility based OR 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. Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events (c)healthcarefirst 09/

20 Testing E 0039 Testing Document: drills, exercises, emergency events, reasons for inability to participate in community based exercises Analyze: response to drills, exercises, emergency events Document: analysis and response Document: resultant emergency program update Maintain records no less than three (3) years Integrated Health System E 0042 If a part of a Healthcare System Option as part of its healthcare program Documentation of Inclusion in the program Actively involved in program development Verified active involvement in the annual reviews/program updates A copy of the entire integrated and unified emergency preparedness program can be produced Leadership can describe how the unified and integrated system works (c)healthcarefirst 09/

21 Resources Federal Register Final Rule /pdf/ pdf Emergency Preparedness Surveyor Guidance Enrollment and Certification/SurveyCertEmergPrep/Downloads/Advanced Copy SOM Appendix Z EP IGs.pdf CMS On line Training Emergency Preparedness health agencies/ homes/ Resources CMS Checklist (2013) Enrollment and Certification/SurveyCertEmergPrep/Downloads/SandC_EPChe cklist_provider.pdf ASPR TRACIE Joint Commission (c)healthcarefirst 09/

22 Resources Louisiana Model HH/Hospice Emergency Plan gency_preparedness/hh_hp_la_model_plan_2014_revised.pdf CDC Personal Preparedness for Older Adults & Their Caregivers Red Cross 96_EmergencyPreparednessChecklist.pdf Questions? (c)healthcarefirst 09/

23 2017 HEALTHCAREfirst Enhancements Exciting HEALTHCAREfirst Partnerships Qualis Management Interface (January) PDC (Palliative Drug Care) Interface (February) ABILITY Interface / firstrev (April) Optum PBM & Medline Medical Supply interfaces (Coming soon) Enhancements in 2017 HEALTHCAREfirst s EHR Software, innovative, fresh new look CAREpliance Care Planning Technology in firsthospice (Coming Soon) NOE Link (Coming Soon) Thank You On demand video will be made available following the webinar. We want to hear from you! Please fill out the survey. Contact HEALTHCAREfirst connect@healthcarefirst.com (c)healthcarefirst 09/