With the new emergency preparedness rule now applicable across the board, CMS is now checking up on all applicable agencies to ensure that they are in compliance. Failure to meet these requirements now comes with real consequences.
Rather than waiting to see whether you receive a Statement of Deficiencies (and then scramble to make corrections in just ten days), it’s best to prepare now for your unannounced visit. Remember, it’s not enough to be prepared for a disaster, you also have to be able to show that you’re prepared.
1. Establishment and maintenance of the emergency program.
What this means: Basically, that all the parts of the plan are in place. In addition, it needs to be updated annually and stay in compliance with all national, state, and local laws.
What they’ll ask:
- They will interview facility or organization leadership and ask them to describe their emergency preparedness program.
- They will ask to see the current plan and documentation on the program.
- They will review the plan to verify that it contains all the required elements.
- If the facility in question is a hospital, they will ask the leadership to describe how the facility used an all-hazards approach to develop its program.
- They will ask leadership to identify the hazards that were identified in the risk assessment and how the risk assessment was conducted.
- They will ask to see documentation of the annual (or more often) review and updates to the plan.
2. Community- and facility-based risk assessments.
What this means: The plan should address not just the impact that “all hazards” could have on the facility itself, but also plans based on disasters in the general region. This should include strategies for each potential impact. Community-based risk assessments can come from or be created in collaboration with public health agencies.
What they’ll ask:
- They will ask to see documentation of the risk assessment and associated strategies.
- They will interview the facility leadership and ask which hazards were included in the risk assessment and why, as well as how the risk assessment was conducted.
- They will verify that the risk assessment takes an all-hazards approach that is specific to the region and encompasses potential hazards.
3. Process for emergency program collaboration.
What this means: There must be a degree of collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response to a disaster or emergency situation, and these efforts to reach out and collaborate need to be documented.
What they’ll ask:
- They will interview leadership and ask them to describe their process for ensuring cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts.
- They will ask for documentation of efforts to contact such officials and (when applicable) participation in collaborative planning efforts.
4. Development of emergency program policies and procedures.
What this means: Emergency policies and procedures should be developed based on the risk assessment. They can either be kept as part of the emergency plan, or incorporated into the general Operating Procedures.
What they’ll ask:
- They will ask to see the written policies and procedures for emergency or disaster situations.
- They will verify that the policies and procedures were developed based on the facility- and community-based risk assessment and communication plan, using an all-hazards approach.
- They will ask to see documentation of the policies and procedures having been reviewed and updated annually.
5. Subsistence needs for staff and patients.
What this means: There needs to be a plan in place for providing food, water, medical supplies, lighting, heat/cooling, waste management, etc. as needed for both patients and staff during an emergency. This plan should take into account the fact that community members may seek shelter at a medical facility in the event of a nearby disaster.
What they’ll ask:
- They will verify that the emergency plan includes policies and procedures for the provision of subsistence needs to both patients and staff.
- They will verify that the emergency plan includes policies and procedures to ensure sufficient alternate energy sources needed to maintain safe temperatures, emergency lighting, and fire safety systems.
- They will verify that the emergency plan includes policies and procedures to provide for sewage and waste disposal.
6. Procedures for tracking, evacuating, and sheltering staff and patients.
What this means: There must be procedures in place for tracking the location of on-duty staff and patients, and this must also include tracking the specific location of all patients in the event of an evacuation.
What they’ll ask:
- They will ask staff to describe or demonstrate the tracking system used to document the locations of patients and staff.
- They will verify that the tracking system is documented as part of the emergency plan policies and procedures.
- They will verify that the emergency plan includes policies and procedures for safe evacuation from the facility.
- They will ask facility leadership to explain the arrangements in place for transportation in the event of an evacuation.
- They will ask to see copies of the arrangements and/or any agreements the facility has with other facilities to receive patients in the event the facility is not able to care for them during an emergency.
- They will verify that the emergency plan includes policies and procedures for how it will provide a means for patients, staff, and volunteers to shelter in place.
- They will review the policies and procedures for sheltering in place and evaluate if they aligned with the facility’s emergency plan and risk assessment.
7. Policies and procedures for medical documents.
What this means: Medical documents needs to be kept secure while at the same time remaining available for continuity of care in the event of an emergency. There also needs to be secure methods in place for sharing information with other healthcare facilities.
What they’ll ask:
- They will ask to see a copy of the policies and procedures that documents the medical record documentation system the facility has developed to preserve patient information, protect confidentiality of patient information, and secure and maintain the availability of records.
- They verify that the communication plan includes a method for sharing information and medical documentation with other health providers to maintain continuity of care.
- They will verify that the communication plan includes policies and procedures that address the means of releasing patient information, including the general condition and location of patients.
8. Development of a communication plan.
What this means: There should be a plan in place regarding communication within a facility, across healthcare organizations, and with public health agencies. The plan should include alternate methods of communication in the event of limited cellular network or internet connectivity, as well as the names and contact information for staff, physicians, other service providers, and volunteers, and of emergency management agencies. It should also include methods for communicating occupancy and the ability to provide assistance to relevant agencies in the event of an emergency.
What they’ll ask:
- They will ask to see the communication plan.
- They will ask to see evidence that the plan has been reviewed on an annual basis.
- They will ask to see the list of all required contacts with their contact information.
- They will ask to see evidence that the contact list has been updated at least annually.
- They will check to see that the communication plan includes both primary and alternate methods of communicating with staff and emergency management agencies.
- They will ask to see the communications equipment or systems listed in the plan, both primary and alternate.
- They will verify that the communication plan includes a means of providing information about the facility’s needs, occupancy (if applicable) and its ability to provide assistance to the relevant authority.
9. Emergency preparedness training program.
What this means: There needs to be a system in place for making sure all staff is aware of the emergency preparedness program and their role within it, including training and testing.
What they’ll ask:
- They’ll verify that there is a written training and testing program that meets the requirements of the regulation.
- They’ll ask to see documentation showing that the training program has been reviewed at least annually.
- They’ll verify that plans also meet requirements for evacuation drills and training.
- They will ask to see copies of both initial and annual emergency preparedness trainings.
- They will interview various staff and ask questions about the initial and annual training.
- They will ask to see a sample of staff training files to verify that staff have received both initial and annual emergency preparedness training.
- They will ask to see documentation of the annual tabletop and full-scale exercises.
- They will ask to see the documentation of efforts to identify a full-scale community-based exercise if one was not participated in. (For example, the dates and agencies contacted and the reasons for not being able to participate.)
- They will request documentation of the analysis and response and how the emergency program was updated as a result.
If all this seems like a lot to think about, that’s because it is.
But effort now can save you stress later, both during your survey and (more importantly) when an emergency requires you to step up and put all your careful work to good use.
Brightgray’s WatchPoint AtRisk Registry will simplify and streamline your organization’s tracking system. Contact us or click the Request a Demo button below to find out what our state-of-the-art system can do for you!
