Emergency Preparedness Rule – Are You Ready?

October 8, 2017

Beginning November 15, 2017, all provider types must comply with the updated CMS condition of participation for emergency preparedness. You can review the Federal Register or 42 CFR §484.22 for the official rule or the CMS’s Emergency Preparedness website for resources including frequently asked questions, a surveyor tool, and CMS online training for Emergency Preparedness. This blog will summarize some of the highlights of the rule for home health agencies but every facility is encouraged to review these resources to ensure that you are in compliance. Be sure to check with your accrediting agency for their updated standards as well.

Emergency Plan

All facilities must have an emergency plan that is reviewed and updated at least annually. Home health agencies must develop this program based on an “all-hazards” approach which analyzes a broad range of emergencies and identifies those situations that are most likely to impact the agency and its staff and clients. Agencies are expected to take into account natural disasters, man-made emergencies, and any other scenario that can impact provision of care. The Office of the Assistant Secretary for Preparedness & Response Technical Resources, Assistance Center, and Information Exchange (ASPR TRACIE) websiteand the FEMA National Preparedness System website have many tools available for agencies to use to document their analysis.

The emergency plan must include strategies to address all potential events that were identified in the analysis. The plan details the services the agency will be able to provide as well as addresses operational continuity with clearly identified lines of authority and alternate staff members who can cover in the event that key employees are not available in an emergency situation.

Agencies are required to have processes for local, tribal, regional, state and federal emergency preparedness official cooperation and collaboration in the plan. Documentation of all efforts to contact officials should be kept to demonstrate compliance or attempted compliance.

Policies and Procedures

Home health agencies are to develop and maintain policies and procedures for emergency preparedness based off of the emergency plan, the all-hazards risk assessment, and the communication plan covered in the next section of this article.

Patient care: Each patient is assigned a patient risk category and has an individual emergency plan developed as a part of the comprehensive assessment, including identification of each patient’s unique physical and mental challenges that could become a factor in coordinating assistance in the event of an emergency. Clinicians must take special note of mobility and transportation issues. Policies must include the method in which patients who require assistance or are not able to be contacted will be identified, how those patients will be referred to state and local emergency officials for evacuation or follow-up and the contents and manner of information to be provided to other entities to ensure coordination of care and confidentiality.

Staff: Procedures include methods of communicating with all staff including determining needed patient services and a plan to inform state and local officials of on-duty staff the agency has lost contact with. If agencies use volunteers, processes must be in place to specify their role in an emergency situation. The means of coordinating with local, state and federal emergency management teams are also to be addressed.

Systems: Agency policies and procedures reflect the method for ensuring that medical records systems preserve patient information and maintain confidentiality while keeping records accessible to staff members coordinating their care.

Communication Plan

The emergency preparedness communication plan is required to be reviewed and updated at least annually. This communication plan contains the names and contact information for staff, contract services, physicians, volunteers and contact information for federal, state, tribal, regional, and local emergency preparedness organizations and other sources of assistance. Additionally, the plan contains alternative means of communicating with all required entities in case primary communication is not usable.

The plan contains the method of sharing patient information and documentation with other providers to preserve continuity of care. This includes the manner in which information about the general condition and location of patients is provided to public or private entities to coordinate disaster relief efforts.

Lastly, a process for evaluating the agency’s needs, ability to provide assistance and communication to authorities is incorporated into the plan.

Training and Testing

Employees are to be educated on the emergency plan when hired and at least annually thereafter with documentation of staff understanding of the materials. This includes direct-hires, people providing services under arrangement (contract employees) and volunteers. Documentation that demonstrates staff knowledge of emergency procedures is required to be maintained. Surveyors can interview any employees about the emergency plan to evaluate the effectiveness of training.

Home health agencies are required to participate in a community-based exercise and an additional exercise, such as a table-top discussion, annually. If the agency is unable to participate in a community-based exercise, documentation is to be kept showing the agency’s attempt to connect with community entities and a full-scale exercise must be done and documented. Analyze and document after both exercises to determine what changes or additions should be made to the existing emergency plan.

Integrated Healthcare Systems

Agencies that are a part of an integrated healthcare system can choose to participate in that system’s coordinated emergency preparedness program. Guidance about collaboration is provided in the regulation.

What do I do now?

Don’t wait! There is a lot of information out there. For agencies looking for step-by-step guidance, here is our recommendation:

  1. Select an Emergency Preparedness team and have them meet as soon as possible.
  2. Perform an “all-hazards” risk analysis – consider using the tools from ASPR TRACIE or FEMA listed above.
  3. Review the EP-tags for your provider type and ensure that policies and procedures are updated to address them.
  4. Contact your local or state emergency management agency to coordinate a full-scale, community-based exercise and maintain documentation of communications in your policies or an emergency preparedness binder.
  5. Make sure all staff, patient, and outside entity contact numbers are up to date and available to top emergency management personnel.
  6. Ensure patients are assigned a risk category, have any physical, mental, mobility or transportation issues documented and have been provided with an individualized emergency plan.
  7. Arrange for staff education on new and updated procedures and maintain documentation of those training sessions.
  8. Arrange to conduct your own full-scale drill (if a coordinated drill is not available to participate in) and a table-top exercise and document your results.
  9. If accredited, contact your organization to see what additional requirements you must follow.

As a modern web-based system, therapyBOSS is available to your emergency management staff as long as they have access to the internet. Contracted clinicians have full offline access to patients assigned to them! Built-in HIPAA compliant messaging can be used in your plan as an alternative method to contact contracted therapists.