Emergency Preparedness

Emergency Preparedness 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 November 15, 2016. However, providers have until November 15, 2017 to be in full compliance.

The National Agenda Over the past several years, many natural and man-made disasters threatened the United States. The September 11, 2001 terrorist attacks, Hurricane Katrina in 2005, and recent Ebola and Zika virus outbreaks are real world examples of homeland security, severe weather, and infectious disease emergences. As a result of these events, our nation s health security and readiness for public health emergencies are on the national agenda.

The General Requirement The facility must comply with all applicable federal, state, and local emergency preparedness requirements. The facility must develop and maintain a comprehensive emergency preparedness program that meets all requirements of the regulation.

The General Requirement The program must include, but not limited to, all of the elements set forth in the requirement. Emergency Plan Policies and Procedures Communication Plan Training and Testing Emergency Power Systems Integrated Health Care Systems

Emergency Plan Standard Develop an emergency plan based on a risk assessment. All business functions essential to the operations that should be continued during an emergency All risks or emergencies that the facility may reasonably expect to confront All contingencies for which the facility should plan The facilities geographic location The extent to which natural or man-made emergencies may cause the facility to cease or limit operations Any necessary arraignments with other health care facilities or other entities to ensure that essential services could be provided during an emergency

Emergency Plan The plan must be based on and include a documented facility-based and community-based risk assessment utilizing an all-hazard approach. Include strategies for addressing emergency events identified by the risk assessment. Be reviewed and updated at least annually. Include documentation of the annual review date and any updates made to the plan based on the review.

Emergency Plan Long-Term Care (LTC) and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) must also include provisions in the emergency plan to account for missing residents.

Risk Assessments Risk assessments should be specific to the location of the facility and consider particular hazards most likely to occur in the surrounding area including, but limited to: Natural disasters Man-made Facility-based disasters

Facility-Based Disasters Facility-based disasters may include, but are not limited to: Care-related emergencies Equipment and utility failures, such as power, water, and gas Communication interruptions, including cyberattacks Loss of a portion or all of a facility Disruptions in normal supplies of essential resources, such as food, water, fuel for heating, cooking and generators, medications, and medical supplies

Natural Disasters Examples of natural disasters include but not limited to: Earthquakes Hurricanes Severe weather Flooding Fires

Emergency Plans Emergency plans must address patient and client populations, including persons at risk, types of services the facility must be able to provide in an emergency, and continuity of operations, including delegations of authority and succession plans.

Policy and Procedures At a minimum the policies and procedures must address a range of issues including: subsistence needs for staff and patients Safe evacuation from the facility procedures for sheltering in place tracking patients and staff during an emergency A system of medical documentation The use of volunteers in an emergency Arrangements with other facilities

Subsistence Needs Provisions for subsistence needs should include, but are not limited to: Food, water, medical, and pharmaceutical supplies Alternate sources of energy to maintain: -Temperatures to protect patient and resident health and safety, and the safe and sanitary storage of provisions -Emergency lighting -Fire detection, extinguishing, and alarm systems -Sewage and waste disposal

Energy Sources Facilities must establish policies and procedures that determine how they will maintain required heating and cooling of the facility during an emergency situation, as necessary, in the event of loss of the primary power source.

Sewage and Waste Disposal CMS does not require facilities to provide on-site sewage treatment; however, facilities must make provisions for maintaining necessary sewage treatment services. Such services may include, but are not limited to: Access to medical gases Treatment of soiled linens Disposal of biohazard materials for different infectious diseases Facilities may also require additional assistance from transportation companies for disposals in accordance with acceptable guidelines.

Sewage CMS does not specify the type of provisions facilities are required to make regarding treatment of sewage and necessary services. Instead, facilities must follow current requirements outside of the emergency preparedness regulation that may address these areas. CMS expects facilities to follow current practices outlined by the Environmental Protection Agency (EPA) and state-specific requirements.

Tracking Patients and Staff Facilities must develop policies and procedures that include a system to track the location of on-duty staff and sheltered patients in the facility s care during and, for some provider and supplier types, after an emergency. In the event on-duty staff and sheltered patients are relocated during an emergency, the facility must document the specific name and location of the receiving facility or other location.

Tracking Patients and Staff CMS does not specify which type of tracking system facilities must use; rather, facilities have the flexibility to determine how best to track patients and staff, whether through an electronic database, hard-copy documentation, or some other method. Facilities must ensure that accurate tracking information is readily available and can be shared as needed among officials within and across the emergency response system. If the facility is using an electronic database they should consider backing up their computer systems with a secondary hard drive, in the event of power outages.

Evacuations and sheltering in Place Emergency preparedness policies and procedures must address the safe evacuation from the facility, including considerations for the care and treatment of evacuees, staff responsibilities, transportation, and identification of evacuation locations, as well as primary and alternate means of communication with external sources and assistance.

Transportation Services Facilities policies and procedures should consider the needs of their patient population when designating which type of transportation services would be most appropriate. For example, if a facility primarily cares for critically ill patients with ventilation needs and life-saving equipment, the transportation services should be equipped for the evacuation of this special population.

Communicating with External Sources Facilities should outline primary and alternate means for communication with external sources for assistance in the emergency policies and procedures. Primary methods may include regular telephone services to contact transportation companies for evacuation or reporting evacuation needs to emergency officials. Alternate means of communication should account for loss of power or telephone services in the local area.

Sheltering in Place Facilities should plan to shelter all persons who remain in the facility in the event an evacuation cannot be executed and sheltering in place is considered a safe alternative. CMS expects facilities to include the criteria in their policies and procedures for selecting patients and staff that would remain sheltered in place.

Medical Documentation Emergency preparedness policies and procedures must address a system of medical or care documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.

Volunteers Facilities may need to accept volunteer support from individuals with varying levels of skills and training during an emergency. Therefore, emergency preparedness policies and procedures must address the use of volunteers or other emergency staffing strategies, including the integration of health care professionals designated to address surge needs during an emergency. Facilities can determine how best to utilize volunteers during an emergency in accordance with state law, state scope of practice laws, and facility policy.

Arrangements with other Facilities Emergency preparedness policies and procedures must address the development of arrangements with other facilities and providers to receive patients in the event of limitations or cessation of operations to maintain continuity of services to facility patients or residents. Such agreements with other facilities and providers must be in writing, such as Memorandums of Understanding (MOU) and Transfer Agreements. Prearranged agreements for transportation between the facilities should be included in the policy and procedures.

Communication Plan The facility must develop and maintain an emergency preparedness communication plan that complies with Federal, state, and local laws. The communication plan must be reviewed and updated at least annually, and must include all of the requirements set forth in the standard. CMS allows flexibility in how facilities formulate and operationalize the requirements of the communication plan.

Communication Plan The plan should support the coordination of patient care during an emergency. The plan must demonstrate how the facility coordinates patient care within the facility, across health care providers, and with state and local public health departments. It should include how the facility interacts and coordinates with emergency management agencies and systems to protect patient health and safety in event of a disaster.

Communication Methodologies Facilities located outside urban areas may have limited access to communication methodologies including the Internet, World Wide Web, and cellular telephones. Facilities that face these situations must address how they will comply with the communication plan. Facilities located in rural environments, for example, with limited or no access to the internet or phone service during an emergency must identify an alternate solution in their communication plan to contact state and local emergency officials. Alternate communication methods include satellite phones, citizens band (CB) radios, and short-wave radios.

Names and Contact Information The facility s communication plan must include names and contact information for the following: Facility staff All entities providing services under arrangement Patients physicians, next of kin, guardian, or custodian Other facilities of similar provider or supplier type Volunteers

Updating Contact Information Facilities must update contact information annually. All contact information contained in the communication plan must be accurate and current. Facilities must update contact information throughout the year with incoming new staff and departing staff and any other changes to information for those individuals and entities on the contact list.

Communication Plan LTC facilities must also include contact information for the State Licensing and Certification Agency and the Office of the State LTC Ombudsman. Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) must also include contact information for the state Licensing and Certification Agency and the State Protection and Advocacy Agency.

Communication Plan The communication plan must include primary and alternate means for communicating with facility staff and Federal, state, tribal, regional, and local emergency management agencies. Facilities may use alternate communication systems that best meet their needs. The plan must include a method for sharing information and medical documentation for patients under the facility s care, as necessary, with other health care providers to maintain continuity of care.

Communication Plan The plan must include a means, in the event of an evacuation, to release patient information as permitted under the Code of Federal Regulations (CFR) with regards to the privacy of individually identifiable health information, known as the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.

Training and Testing Facilities must develop and maintain an emergency preparedness training and testing program based on the emergency plan, risk assessment, policies and procedures, and communication plan standards set forth in the emergency preparedness requirement. Maintain documentation of the training. Demonstrate staff knowledge of emergency procedures. The training and testing program must be documented, reviewed, and updated on at least an annual basis.

Training and Testing Training is required for all new and existing staff members, individuals providing services under arrangement, and volunteers, consistent with their expected role during an emergency. Training must include individuals who provide services on a per diem basis. Such individuals might include agency nursing staff or any other individuals providing services on an intermitted basis who the facility would expect to assist during an emergency.

Training and Testing CMS recommends that new staff members complete initial emergency training by the time they have completed the facility s new hire orientation program to ensure that the training is not delayed. For facilities with multiple locations, initial training for staff individuals providing services under arrangement, and volunteers should be provided at their specific location as well as any new location they are assigned.

Training and Testing Ideally, facilities should modify their annual training each year and incorporate lessons learned from the following: Most recent exercises Real-life emergencies that occurred in the last year Annual review of the facility s emergency program

Training and Testing Depending on the individual's specific duties during an emergency, the facility may determine that documented external training is sufficient to meet the facility's requirements. Large health systems may develop an integrated emergency preparedness program that includes an integrated training program for all of their facilities. However, the training at each separately certified facility must address the individual needs of the specific facility type and maintain individual training records to demonstrate compliance.

Training and Testing The facility must conduct exercises to test the emergency plan at least annually. LTC facilities must include unannounced staff drills using emergency procedures in their annual testing. ICF/IID must also satisfy the requirement for evacuation drills and training.

Full-Scale Exercises The facility must participate annually in a full-scale community-based exercise or, when a community-based exercise is not accessible, an individual facility-based exercise. 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 one year following the onset of the actual event.

Additional Exercises The facility must conduct an additional exercise annually that may include, but is not limited to, the following: A second full-scale, community-based or individual facility-based exercise A Tabletop Exercise (TTX) 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.

Additional Exercises Full-scale exercises and TTXs must reflect the risk assessment required as part of the facility s emergency plan utilizing an all-hazards approach. The facility must analyze its response to all drills, TTXs, and emergency events, and revise its emergency plan as needed. Facilities must document their compliance with testing requirements and ensure access to that information at all times for a minimum of three years.

Documenting Exceptions Not all facilities are located within states or local areas that readily offer community-based exercises to fulfill the fullscale exercise requirement. CMS anticipates that facilities would first contact their local and state emergency preparedness agencies to inquire about suitable opportunities available for participation in a community-based exercise. If no suitable opportunities are available, facilities should document which agencies or organizations and personnel they contacted, and the date they contacted each.

Community-based Requirement If a facility is unable to identify a full-scale, communitybased exercise in which to participate, it may fulfill this part of the requirement through one of the following : Conducting an individual facility-based exercise Documenting an emergency that required them to fully activate their emergency plan. Conducting a smaller community-based exercise with other nearby facilities.

Community-based Requirement The sole responsibility for compliance with the testing requirement rest with the individual facility. If a facility is not able to participate in a state or local full-scale community exercise, it may choose to collaborate with other nearby facilities to coordinate a community-based exercise that satisfies the requirement for a full-scale exercise.

Community-based Requirement If a LTC facility, hospital and an End- Stage Renal Disease facility within a reasonable geographic location may coordinate and complete a community-based exercise together, if local or state community-based exercises are not available.

Full-scale Exercises CMS does not expect facilities to conduct a full scale exercise as defined by FEMA. Instead, surveyors and facilities should follow the CMS definition for full-scale exercise as it appears in Appendix Z. Facilities that conduct an individual facility-based exercise must demonstrate how the exercise address risk identified in the facility risk assessment.

Analysis and Review Facilities must document lessons learned from TTXs, full-scale exercises, and real-life emergencies and demonstrate the incorporation of any necessary improvements in their emergency preparedness programs. Facilities should conduct an after-action review process involving facility leadership, department leads, and critical staff capable of identifying and documenting lessons learned and necessary improvements in an official, actionable After Action Report (AAR).

After Action Reports At a minimum, the AAR should determine: What was suppose to happen What actually occurred What went well What the facility can do differently or improve upon The AAR should also include a plan with timelines for incorporating necessary improvements.

Emergency and Standby Power Hospitals, CAHs and LTC facilities must implement emergency and standby power systems based on the emergency plan and policies and procedures standards set forth in their respective emergency preparedness program requirements.

Generator Requirement For hospitals, CAHs and LTC facilities, the EES alternate source of power is typically a generator; however, these facilities should base their determinations for emergency and standby power systems on their emergency plan, risk assessment, and policies and procedures. If the facility determines that it does not require a generator to meet emergency and standby power systems requirements, then the emergency preparedness standards at (e)(1) and (e)(2) would not apply.

Emergency Power Decisions Each facility must make emergency power system decisions based on its own risk assessment and emergency plan. A nursing home may decide to relocate residents to a certain part of the facility where it can maintain proper temperature requirements rather than plan to maintain temperatures in the entire facility.

Portable and Mobile Generators NFPA 110 requires that EPSS equipment, including generators, be designed and located to minimize damage and be permanently attached. Therefore, CMS does not allow portable and mobile generators as options for providing or supplementing emergency power to hospitals, CAHs, or LTC facilities.

Compliance Facilities are expected to be in compliance with the requirements by 11/15/2017. In the event facilities are non-compliant, the same general enforcement procedures will occur as is currently in place for any other conditions or requirements cited for non-compliance.

Providers and Suppliers should refer to the resources on the CMS website for assistance in developing emergency preparedness plans. The website also provides important links to additional resources and organizations who can assist. https://www.cms.gov/medicare/provider-enrollment-and- Certification/SurveyCertEmergPrep/index.html https://surveyortraining.cms.hhs.gov

Contact Information Brent Maroney Life Safety Code Surveyor/Supervisor OSDH 405-271-6868 BrentM@health.ok.gov Nakia Jackson Life Safety Code Surveyor OSDH 405-271-6868 NakiaM@health.ok.gov Long Term Care/10 th Floor 1000 N.E. 10 th St Oklahoma City, Ok 73117