Be Prepared Achieving Compliance with the CMS Emergency Preparedness Requirements for PACE Bill Kirkpatrick, PACE Organization of Rhode Island Eileen Kunz, On Lok Lifeways Anita McClendon, On Lok Lifeways Chris van Reenen, National PACE Association
Session Overview Brief overview of emergency preparedness requirements for PACE organizations Overview of 2 PACE organizations and their approaches to emergency preparedness: PACE Organization of Rhode Island and On Lok Lifeways Focus areas: Establishing collaborative relationships Communications plan Training Testing Questions & Answers
Emergency Preparedness Final Rule CMS issued EP final rule on 9/16/2016 with an implementation deadline of 11/15/2017 (30 days and counting) EP rule establishes new 460.84 Emergency Preparedness replacing 460.72(c)
Goals of Emergency Preparedness Rule Address Systemic Gaps Establish Consistency Encourage Coordination
Emergency Preparedness Program: Core Elements Risk Assessment and Planning Policies and Procedures Emergency Preparedness Program Communication Plan Training and Testing
Risk Assessment PACE organizations must assess their risk for both: Internal emergencies that affect the PO itself Emergencies that affect the community at large Emergencies include: Care-related emergencies Equipment and power failures Communications interruptions, including cyberattacks Both natural and man-made disasters
Emergency Preparedness Plan How to maintain essential business functions during an emergency? What emergencies should your PACE Organization (PO) prepare for? What contingencies should your PO plan for? Where are services provided? Where are business operations performed? What arrangements/strategies are necessary to ensure essential services are provided during an emergency? Does the PO s plan address the needs of its participant population? Does the PO s plan involve cooperation and collaboration with EP officials at all levels?
Policies & Procedures To meet subsistence needs for participants and staff in event of need to shelter in place or evacuate To track the location of on-duty staff and participants To safety evacuate from the PACE center including P&Ps that address care and treatment needs, staff responsibilities, transportation, evacuation locations, means of communication To inform State and local EP officials about participants in need of evacuation from their homes To shelter in place To preserve and protect confidentiality of participant information, and secure and maintain availability of participants records To utilize volunteers or for other emergency staffing strategies To work with other providers to maintain continuity of services To address the role of the PO under a Sec. 1135 waiver, if declared by the Secretary To insure availability of emergency equipment
Communication Plan Names and contact information for staff and contractors, etc. Contact information for Federal, State, tribal, regional, and local EP staff Contact information for other sources of assistance Primary and alternate means of communication with staff and emergency management agencies Method for sharing participants information and medical documentation to maintain continuity of care Means to release information consistent with HIPAA requirements Means of providing information to authorities about the PO s needs and ability to provide assistance
Training and Testing Initial and annual training for staff, participants, contractors, volunteers, etc. Staff must demonstrate knowledge of emergency procedures Annual testing involving at least one community-based or facility-based full-scale exercise, and either a second full-scale or table-top exercise Importance of documentation
Achieving Compliance with CMS Emergency Preparedness Requirements for PACE Organizations
PACE Organization of Rhode Island PACE Organization of Rhode Island (PACE) is a non-profit health plan and provider of care for Medicare and Medicaid adults 55 and older who have chronic health needs and want to live at home. Exclusive PACE provider in Rhode Island with locations in Providence, Westerly and Woonsocket. Only risk-based, integrated community-based model specifically designed for high-risk elders. We have served over 700 frail adults since opening in 2005
PACE Organization of Rhode Island Our Participant Profile: Close to 300 ppts currently enrolled Average age is 75 12% aged between 55 and 64 20% aged 85 or older 69% female / 31% male 54% speak a primary language other than English 94% are low-income seniors who are eligible for both Medicare and Medicaid 36% have a formal diagnosis of dementia, including Alzheimer s disease 46% have six or more chronic health conditions compared to 14% among RI Medicare fee-for-service (FFS) beneficiaries 33% have 3 or more ADL limitations Enrollment Average 4.3 years 35% of current participants have been enrolled five years or more
On Lok Lifeways Emergency Preparedness Program October 17, 2017 committed to serving California s diverse communities
On Lok Overview Original Vision: Help the low-income seniors in Chinatown/North Beach area of San Francisco stay in their own homes National prototype for the Program of All-inclusive Care for the Elderly (PACE) model of care Today: 15 On Lok Lifeways, our PACE program, serves over 1,450 seniors in three San Francisco Bay Area counties On Lok s 30 th Senior Center services over 6,000 seniors annually with traditional senior center services Owns and operates three senior housing buildings Provides consultation through PACEpartners consulting Owns Care at Home Medicare home health agency 1
On Lok History Served Chinatown/North Beach neighborhoods from 1973 to 1995 with four PACE centers Expanded PACE throughout San Francisco in 1996 with subcontract with Institute on Aging (IOA) and acquisition of 30th Street Senior Services Expanded to City of Fremont in 2002, using community physicians Expanded to City of San Jose to serve Santa Clara County in 2009 Opened a second PACE center in Fremont with co-located housing. Opened the East San Jose ADHC center in 2014 to serve as alternative care setting to San Jose PACE center. Consolidated two Fremont PACE centers into one in May 2017 Converting East San Jose center into full PACE center in 2017. 16
On Lok Lifeways Service Area SAN FRANCISCO COUNTY Entire county/city served 4 PACE centers/7 IDTs Administrative Offices ALAMEDA COUNTY Fremont, Newark & Union City 1 PACE center/2 IDTs 1 Alternative care settings Administrative Offices SANTA CLARA COUNTY Entire county (except Gilroy, Morgan Hill & San Martin) 1 PACE centers/2 IDTs 3 Alternative care settings 17
Geographic and Population Differences Service Area Geographic Area (Square Mi.) Population San Francisco 47 837,442 Alameda (Fremont, Union City and Newark) 110 341,546 Santa Clara 1,290* 1,862,041 *Includes entire county not only On Lok service area 18 6
2017 HVA Summary
Incident Command System (ICS) Structure 20
Command Staff 21
PACE Center ICS Structure Normal PACE program services will be delivered through branches under the Operations Section: o Well Care o Clinical Care o Transportation 22
ICS Across On Lok Gee Administration will form its ICS team and communicate with all sites from Gee Center. Gee Admin (OCC) Jade / Rose Peralta Powell East San Jose 30 th Street San Jose 23
Establishing Collaborative Relationships RI Emergency Management Agency Rhode Island LTC Mutual Aid Plan Carelink Post Acute Health System Rhode Island DOH Center for Emergency Preparedness and Response Providence Emergency Management Agency/Port of Providence Evacuation Plan
Mutual Aid Agreements Steere House White Cross Pharmacy St. Antoine s Catering Service Alternate PACE sites in RI
Policies & Procedures Emergency Management Program Plan - Template P&P based on our identified hazards Participants of Concern procedures RI Special Needs Registry Port of Providence Evacuation Plan
27 Communication
Emergency Communication Communication plan required and under development Focus on internal communication Staff, participants, contract providers, volunteers and board PACE Center Incident Commander to Gee Admin Establish discrete number of key contacts and alternates if first contact isn t available Minimal calls to activate Various modes of communication Communication within center and between centers Communication with community partners and emergency officials 28
Types of Communication Type Purpose Example Alert Action Required/ Activation 29 Notification Report incident and no action needed as this time. On alert to monitor for possible future action. Action required to respond to incident. Activation of Organizational Coordination Center - Incident Command System. Inform leadership and staff of status and/or incident resolution. Rolling brownouts are occurring in San Francisco. Temporary outages may occur in next 8 hours. There s power outage at Gee center with no timeframe for resolution. Elevator stuck between floors with participant and staff in it. There was power outage last night. Power is back on. All systems operating normally. Events that pose a potential or actual disruption of program services requires initiation of ICS.
Emergency Communication Tools Tools Purpose Phone Trees Contact direct care staff GETS/WPS (Landline & Cell priority) Send Word Now Notification System Cut through congestion of landlines and cell networks. Quickly alert, inform or call-back staff. VHF/UHF Radios Inter-site communication redundancy in event that digital communication lines fail Emergency Landlines at each center Provide fallback in case digital communication lines fail 30
Lessons Learned Ongoing maintenance needed Keeping information up to date with staff changes and location moves Testing equipment and battery on regular basis Reliance on cell phones demands alternative power sources New technologies allow for more flexibilities and more complexity Multi-county service area requires understanding of county-level emergency communication systems 31
32 TRAINING & TESTING
Training & Testing HVAs conducted for all centers in the spring HVA results informed training and testing design Training and Testing Components Ongoing regular fire drills Training & Tabletop - early summer Community-based exercise - fall
Training with Tabletop Training (1-hour) Reinforcing previous life safety Fire & Earthquake Emergency supplies Evacuation maps Introduced concept of Standard Responses Reviewed Center-based ICS Section Chief roles and redundancy Introduced Branch Directors Assigned each discipline to a branch
PACE Center ICS Sections & Branches CENTER-BASED INCIDENT COMMANDER Section OPERATIONS CHIEF PLANNING CHIEF LOGISTICS CHIEF Transportation Documentation Transporting Documenting, participants, staff, collecting, and and equipment as maintaining needed to ensure information about safety. the incident. Functional Branch Well Care Personal care and support of participants who do not currently require medical attention (Green card) Clinical Care Providing clinical services to participants and staff in need of medical treatment or attention (Red card) (Blue card) (Orange card) Center Support Monitoring and reporting incident status from external sources. Monitoring and directing incoming calls. (Yellow card) Resources Food, water, and medical supplies for subsistence, manpower, and other items as needed. (Beige card) Facilities & Infrastructure Building, power, water, sewage, IT and telecom integrity. (Grey card) Staff Center & HC GAs Activities Nutrition Social Work/ Behavioral Health/ Chaplaincy HC RN s Medical Assistants Clinic Nurses (RN s, LVN s) PCP s Transportation Medical Records Center Assistant Reception Admin Support Rehab HR Facilities IT
ASSIGNMENT CARD EXAMPLE On Lok Center-Based Emergency Response Assignment WELL CARE BRANCH RESPONSIBILITY: Personal care and support of ambulatory and non-ambulatory participants who do not currently require medical attention STAFF INVOLVED: Center Geriatric Aides Homecare RNs Nutrition Chaplaincy Activities Homecare Geriatric Aides Social Work Behavioral Health REPORTING LOCATION: Day Center LEADER: Well Care Branch Director (under the Operations Section) TASKS: Normal job duties including assistance with toileting and personal care as needed Keep participants safe, grouped together and away from windows or other possible hazards. Calm, reassure and engage participants. Assist with meal service. Escort participants to safe locations as directed. Coordinate care of participants in community if safe to do so. Observe and report concerns, incidents or hazards to Group Leader. Other tasks as needed
Training with Tabletop Table top: Active shooter as identified in HVA Involved all center staff rather than just ICS Design Adapted timeline from real event Elected to minimize stress shooter outside of building Broke after each inject to answer 1-2 questions Challenges Space for large groups Need for interpreters Appropriate number of injects Evaluation/After Action Identified areas of concern General feeling of appreciation and desire for more training
TABLETOP EXERCISE AGENDA 2:00 Tabletop Exercise Briefing 2:05 Exercise Begins 3:30 After Action Report 3:50 Training Evaluation and close out TABLETOP EXERCISE SETUP It is a normal, mid-week summer day for the center. Most participants have arrived but some who had early offsite appointments are still in transit. The morning IDT meeting is over and a staff member is at the front desk talking to the Receptionist.
TABLETOP EXERCISE INJECT #1 (Large group) 10:38 AM Receptionist and another employee are at the front desk and hear popping sounds from outside and then, a few seconds later, what sounds like a car accident. REFLECTION Based on the information presented in Inject 1: 1. What actions would you consider taking, if any, at this stage? 2. What concerns might you have?
TABLETOP EXERCISE INJECT #2 (Large group) 10:39 AM Van Driver calls center PM to report that he is diverting from the center because there is a car blocking the road about 300 feet from the center, he thinks he s heard gun shots, and saw a person standing near the car holding what appeared to be a gun. REFLECTION Based on the information presented in Inject 2: 1. What actions should be taken to secure the area? 2. Who is responsible for contacting law enforcement? What information should be relayed?
TABLETOP EXERCISE 10:45 AM INJECT #3 (Large group) Sirens can be heard as the first police units and ambulance arrive on scene. Exchange of gunfire seems to be coming from outside but near the center. REFLECTION Based on the information presented in Inject 3: 1. What actions should you take? 2. What, if anything, should participants be told at this time?
TABLETOP EXERCISE INJECT #4 (Large group) 10:52 AM SWAT arrives Emergency Services is calling homes and businesses in the immediate area to apprise them of the situation and has advised you to shelter-in-place Police begin door-to-door search for suspect Please proceed into the designated breakout groups to carryout the next three injects of this exercise.
TABLETOP EXERCISE 11:00 AM INJECT #5 (Breakout groups) An employee reports hearing the handle of the back emergency door being tested, pounding on the door and someone yelling, Let me in, let me in. REFLECTION Based on the information presented in Inject 5: 1. What action, if any, will you take to ensure the facility remains secure? 2. What will you do about the person outside your door?
TABLETOP EXERCISE INJECT #6 (Breakout groups) 11:20 AM Participants are beginning to complain about being hungry (due to police activity, lunch and portable meals were not delivered to the center). REFLECTION Based on the information presented in Inject 6: 1. How will you meet participant needs? 2. What plans will be made for portable meal delivery?
TABLETOP EXERCISE INJECT #7 (Breakout groups) 11:45 AM Some participants are watching news and twitter feeds via their cell phones and sharing the information with those around them. Anxiety levels appear to be rising within part of the group. One participant begins to hyperventilate and appears to be having a panic attack. Another participant becomes extremely agitated and complains that he doesn t feel safe in the building and wants to get out there where the cops can protect me. As he attempts to leave the group, he roughly shoves a staff person who loses her balance and falls heavily onto her right elbow. As the staff person attempts to right herself, she cries out in pain and it becomes apparent that she has dislocated her shoulder. REFLECTION Based on the information presented in Inject 7: 1. What is the priority for addressing these issues (group anxiety, panic attack, attempt to leave, dislocated shoulder)? 2. How will each issue be addressed?
TABLETOP EXERCISE 12:30 PM INJECT #8 (Large group) For over an hour there has been no sound from outside the center. Staff are receiving calls from family members and participant caregivers who have learned of the active shooter situation. Emergency personnel can be seen outside. Several staff express interest in leaving. REFLECTION Based on the information presented in Inject 8: 1. Who is responsible for deciding when it is safe to leave the secure area?
TABLETOP EXERCISE 12:45 PM INJECT #9 (Large group) Law enforcement personnel arrive outside the center door and direct you to evacuate the building. REFLECTION Based on the information presented in Inject 9: 1. How do you comply with law enforcement s specific evacuation instructions while maintaining participant safety?
TABLETOP EXERCISE HOTWASH Tabletop Exercise has concluded. 1. What went well? 2. What needs work? 3. Ideas for improvement?
Community-based exercise September 14, 2017 One county Two centers participated in county s public health exercise Many agencies public health, hospitals, SNFs, ADHCs, Dialysis Centers, clinics etc. October 25, 2017 All center exercise Likely partners local police & fire, other PACE center, other ADHC Major event resulting in power outages, building damage, bridge & roadway damage, public transportation damage, etc. Testing communication, appropriate delegation of tasks, and incident action planning
Testing (Full Scale & Table Top) All Hazard s Approach Hazard Vulnerability Analysis (HVAs) Plans and drills associated with the top 5 hazards Live drills annually at 3 sites Table Top Exercise Annually including 3 sites
Incident Log
Table Top
Examples of Drills Held Snowstorm/power outage/state of emergency declared by Governor/shelter in place Hurricane/power outage Fire Drill/full evacuation of building Contingency planning for potential absence of physicians due to travel restrictions
Questions & Answers
Words to live by Be prepared! Boy and Girl Scouts Motto