Deadline Approaches for Compliance with CMS Emergency Preparedness Requirements.
With the headlines full of news about Hurricane Harvey hitting the Texas coast, this is a good time for healthcare providers to remember the pending deadline to comply with the Centers for Medicare and Medicaid Services (CMS) emergency preparedness requirements. CMS defines the Emergency Preparedness Program as a healthcare facility’s comprehensive approach to meeting the health, safety, and security needs of the facility, its staff, their patient population, and community prior to, during, and after an emergency or disaster.
By November 16, 2017, all clinics, long-term care facilities, and ambulatory surgery centers must comply with the Medicare and Medicaid Programs: Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers Final Rule (81 FR 63860).
This rule requires certain Medicare and Medicaid participating providers and suppliers, specifically hospitals, critical access hospitals, long-term care facilities, home health agencies, comprehensive outpatient rehabilitation facilities, federally qualified health centers, rural health clinics, end-stage renal disease facilities, and ambulatory surgical centers, to comply with all applicable federal, state, and local emergency preparedness requirements.
Examples of disasters for which healthcare providers must be prepared include:
-
Hurricanes
-
Tornados
-
Fires
-
Earthquakes
-
Power outages
-
Chemical spills
-
Nuclear or biological terrorist attack
-
Pandemic flu (e.g., H1N1 influenza virus)
CMS has released a new Appendix Z to the Medicare State Operations Manual to include interpretive guidelines for 17 different provider/supplier types. The Appendix provides details on guidelines and strategies on the four core elements that organizations must address through an Emergency Preparedness Program. These are:
EMERGENCY PLAN. An Emergency Plan must be based on a documented, facility- and community-based risk assessment that describes the process facilities use to assess and document potential hazards that are likely to impact their geographical region, community, facility, and patient population. The assessment must identify gaps and challenges to be considered and addressed when developing the Emergency Preparedness Program. The Emergency Plan must use an “all-hazards approach,” which is an integrated method of emergency preparedness planning.
This approach focuses on capacities and capabilities that are critical to preparedness for a full spectrum of emergencies or disasters specific to the location of a provider or supplier. Possible events include internal emergencies and man-made emergencies—or both—or natural disasters. Examples include care-related emergencies, equipment and power failures, interruptions in communications, including cyber-attacks, loss of a portion or all of a facility, and interruptions in the normal supply of essentials such as water and food. The Emergency Plan must be reviewed and updated annually.
COMMUNICATION PLAN. Developed to comply with federal, state, and local laws, the Communication Plan ensures that patient care is well-coordinated within the facility, across health care providers, and with state and local public health departments and emergency systems. The Plan must be reviewed and updated annually.
TRAINING AND TESTING PROGRAMS. Providers must develop, maintain, and conduct training programs. All new hospital personnel, volunteers, and individuals must have initial training, followed by annual instruction thereafter. Providers must also develop and maintain testing programs, including drills or exercises, or participate in an actual incident that tests the Emergency Plan at least annually. CMS encourages providers and suppliers to participate in full-scale, community-based exercises with local and/or state emergency agencies and coalitions and to have completed a “tabletop” exercise by the implementation date.
POLICIES AND PROCEDURES. In addition, providers must develop and implement policies and procedures based on the Emergency Plan, Communication Plan, and risk assessment. Policies and procedures must address, but are not limited to:
-
Evacuation or provision of shelter for patients
-
Food, water, medical, and pharmaceutical supplies
-
Alternate sources of energy
-
Emergency lighting
-
Fire detection, extinguishing, and alarm system
-
A system of medical documentation that preserves patient information and protects confidentiality of patient information
Providers that have not completed their training and testing exercises, or have not implemented any other requirements of the Final Rule upon their CMS survey, will be cited for non-compliance. As Hurricane Harvey demonstrates, disasters are real. Complying with the CMS Emergency Preparedness Requirements is an important way healthcare providers can be sure they are ready to withstand an emergency event when one occurs.
