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 How to Prepare for the New CMS Rule for Emergency Preparedness

The new 186-page rule is a complete paradigm-shift in how providers prepare and respond to emergencies.   

 

New emergency preparedness requirements included in a Centers for Medicare & Medicaid Services (CMS) final rule titled Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, became effective Nov. 15, 2016 and the implementation date is Nov. 15, 2017.

All Hazards Focus

Emergency Preparedness Plans (EPPs) must now comprehensively focus on the “All Hazards” approach to emergency management.  An “All Hazards” approach includes mitigation, preparedness, response, and recovery, and must address protocols to eliminate or minimize disruptions to providers during emergency incidents.

The new CMS rule requires that providers prepare for natural and/or man-made disasters following nationally recognized protocols and requirements. The Federal Emergency Management Agency (FEMA), National Incident Management System (NIMS), and the Incident Command System (ICS) are referenced throughout the CMS rule. There are also specifications that providers coordinate their EPP with local, state, and federal agencies.

Together with the providers’ state and local requirements for emergency management policies, the EPP must outline a comprehensive response plan for a full spectrum of emergencies and disasters. There are three overarching concepts in the new rule: safeguard human resources, maintain business continuity, and protect physical assets. There are four categories for implementation: risk assessment and emergency planning, policies and procedures, communication plan, and training and testing.

Follow this Basic Format

The rule does not specify a template to follow in the development of the emergency preparedness plan. However, adopting the protocols of FEMA, NIMS, and ICS, as referenced in the CMS rule, is recommended. The following basic format includes FEMA protocols as well as the required components of a hazard vulnerability analysis (HVA) and starts with the section titled: “Purpose.”

Purpose

Describe how your EPP is an “All-Hazards” approach for emergency planning and response: All-Hazards is an integrated approach to emergency preparedness planning that places a focus on capabilities/capacities that are essential for effectively responding to emergencies and disasters. The EPP applies to all members of program administration and staff in all departments. The EPP also applies to non-staff members who perform work at the site including clinical providers, technicians, contractors, students, volunteers, and ancillary staff.

Services Available

Describe your facility and operation. An example for a nursing home could include square footage, number of rooms and beds, clinical and other services offered, programming, and departments, etc. Mention whether the facility can potentially serve to temporarily support an influx of injured or medically compromised patients during a disaster.   

Authority, Situation, and Assumptions

Detail oversight authority of the operation (i.e., board of directors [BOD], CEO, executive director, etc). Outline positions responsible for day-to-day management. Describe who’s in charge when senior staff are absent. In the case of an emergency after normal working hours—a worst case scenario—detail emergency preparedness plan protocol that applies to most senior staff on duty.  

Situation description for a skilled nursing facility would include physical plant outline, 24/7 operation, bed-capacity, departments, number of staff, and that the facility is responsible for the safety and protection of its residents and staff. Merge into the Assumptions category by revealing that facility staff have received EPP training for a worst-case scenario and will mobilize off-duty personnel to mitigate vulnerabilities and assumptions:  

Assumption examples:

  • Emergencies and disasters can occur without notice, any day, and on any shift.  
  • Local authorities can declare an emergency and the disaster may be local or state-wide
  • The facility may receive requests for resource support (supplies, equipment, staffing, or shelter) from other health care facilities.
  • Facility security may be compromised during an emergency.
  • Emergency may exceed the facilities’ capabilities and external emergency resources may not be available. Therefore, the facility will manage the incident without these resources.

:##:

Mitigation

Mitigation is the procedure for risk analysis and emergency planning. The goal of mitigation is to eliminate or minimize the impact of emergencies/disasters on day-to-day operations. During mitigation, internal/external hazards that pose potential harm to the operation will be identified and analyzed. Mitigation activities are dynamic and should occur both before, during, and following a disaster/emergency.

HVA is the primary mitigation tool to highlight threats and measure potential impact on the operation. HVA is a new concept for long term care providers and the tendency is to over-analyze the technicality of the process—but keep it simple. Below is an example of an HVA that addresses a full-spectrum of potential threats with a simple classification and measurement system:

Hazard Vulnerability Analysis (HVA)

0=None

1=Rare

2=0ccasional

3=Frequent

Event

0=No Impact

1=Limited

2=Substantial

3=Major Impact

 

0=No Impact

1 -Limited

2=Substantial

3=Major Impact

 

Total Risk

Number

 

Hazard

Likelihood of Event

Impact on

Population

Impact on Property

Total

 

Dam Failure

1

2

2

5

Drought

2

2

1

5

Earthquake

2

2

3

7

Flood

1

1

1

3

Tornado

0

0

0

0

Wild Fire

1

1

1

3

Winter Storm (Severe)          

1

1

1

3

Hazard Materials Transportation

1

1

1

3

Power Failure

2

2

2

6

Transportation Rail/Air

1

2

1

4

Urban Fires

2

1

1

4

Civil Disorder

1

1

1

3

Nuclear Attack

0

0

0

0

Active shooter

1

2

2

5

Cyber-attack/hacking

2

2

1

5

 

 

Develop an action plan to include in the EPP that highlights the number one risk. This action plan should provide background on earthquakes, provide safety education and procedures for staff, and describe mitigation efforts.

Preparation and Testing

Disaster preparedness is promoted through a comprehensive EPP training and testing program involving all employees. Proof of practice for training and competency for executing the plan is documented and retained by designated operation supervisors. New employees will receive EPP training during new hire orientation and refresher training is provided throughout their employment. Emergency execution of the EPP is conducted twice a year—for all staff—to test the efficacy of emergency response and subject-matter knowledge of staff. The drills and testing will provide a variety of disaster scenarios that have been identified in the HVA.     

Key management staff will be trained as subject-matter experts on the EPP and designated to fine-tune drill response by providing real-time instruction/feedback as drill is executed. The testing will be documented and include date, time, staff attendance, and a summary outlining efficacy of emergency response. Reports of emergency preparedness testing are submitted to the Local Governing Body through the Quality Assurance and Performance Improvement (QAPI) Committee for review and further refinement.

Response

Facility staff respond to emergencies/disasters by executing the EPP which is based on a framework of national and state emergency preparedness best practices for healthcare systems and the NIMS: a systematic approach to direct staff to respond proactively to incidents involving threats and hazards. The goal of the response is to minimize loss of life, property damage, or harm to the local community. The following concept is integrated into the facility EPP and training curriculum for disaster preparedness:

Incident Management System: The Facility Incident Command Center (FICC) and the designated Incident Commander (IC) are consistent with the NIMS protocols: Establish a central location in the facility as the FICC with phone lines, computer terminals, adequate seating, white boards, TV monitor, and radios. The FICC delineates the integrated approach for controlling personnel, facilities, equipment, and communications. Not all events will require a full-scale activation. Activation of the FICC will be determined by the Incident Commander.

Activation of Disaster Organization Chart

During the mobilization stage of an emergency response the facility transitions from the normal organization chart to the disaster organizational chart. This organization chart is based on the FICC platform, which follows the framework of both the NIMS and regional/local government response agencies. The following chart organizes response functions into five areas and the incident commander designates key staff to act as support commanders:

 Incident Commander (IC)

  • Direct and facilitate on-scene response
  • Appoint incident command positions and responsibilities
  • Plan situational briefs
  • Determine the incident objectives and strategy; determine mission-critical information, facilitate planning/strategy meetings
  • Identify priorities and activities; provide impact assessment for business continuity and crisis communications
  • Review and approve resource requests
  • Terminate the response and demobilize resources

Logistics

  • Provide resources for support personnel, systems, and equipment:

  • Meeting space
  • Media briefing center
  • Transportation
  • Communications equipment
  • Food, water, shelter, and first aide

  • Facilitate communications between staff/local officials/licensing and emergency agencies
  • Provide logistics input at planning meetings and updates on resources (availability, response time, deployment)

Planning

  • Schedule and facilitate planning meetings
  • Supervise development of action plans
  • Ascertain need for subject-matter experts to support response efforts
  • Coordinate business continuity
  • Assess current and potential impacts on facility

Finance

  • Manage financial aspects of incident
  • Provide cost analysis as needed
  • Track staff time and incident-related costs
  • Document claims for damage, liability, and injuries
  • Notify insurance carriers
  • Provide incurred and forecasted costs at planning meetings
  • Monitor financial expenditures, new leases, contracts, and agreements in compliance with CMS conditions-of-participation

Operations

  • Manage tactical operations
  • Develop operation plan
  • Ensure safe tactical operations for emergency responders
  • Request resources to support tactical operations
  • Expedite changes in operations plan as necessary

:##:

Emergency Communication Plan

Facility provides for a variety of communication redundancies for emergency events. Off-duty staff mobilization is initiated via:

  • Departmental employee call-in lists
  • Batch email and texting
  • Call-in hotline with tailored message

External communication during emergencies will be coordinated by the FICC designee.  The EPP details specific emergency plans for external agency notification requirements. Residents of the facility will be kept informed of events by members of the FICC.  Additional communication redundancies include the following:

  • Emergency codes: Paged overhead 
  • Land lines: Hard-wired for internal/external communications
  • Cellular phones/texting: Department head and personal cell phones can be used if hard lines become inoperable.
  • Two-way Radios:  FICC will distribute for internal communications  
  • HAM Radios: Amateur radio operations as the situation dictates
  • Internet: For multi-media communication
  • Media Outlets (radio, news)
  • Emergency weather radio: Keeps facility staff aware of current conditions that may impact operations.
  • Runners:  If all else fails staff can serve as runners to distribute or retrieve information (internally and externally)

Emergency Documentation and Tracking

Emergency/Disaster response is documented and tracked on the Facility Incident Tracking Form. This report will be initiated and completed by facility senior staff on duty at time of incident. The Facility Incident Tracking Form is considered a dynamic document and is updated by the Incident Commander throughout the emergency management process.

Demobilization and Transition to Recovery

The IC, or designated authority in consultation with other FICC members, will determine when the emergency has stabilized sufficiently to scale back EPP activation and begin demobilizing. The IC will assign appropriate individuals to carry-out demobilization efforts and return the facility back to normal day-to-day operations.

Recovery for Critical Services

The EPP will detail event-specific recovery plans to determine when to resume and continue critical operational functions. It’s critical to assess remaining hazards, protect staff and resident safety, while evaluating the extent of damage and disruption to continuity-of-operations.

The FICC will compile and maintain detailed records of damaged-related costs through documentation, photography, and video technology. Recovery actions will be executed per previously established operational business services plans.

Depending on the emergency's impact on the facility, recovery may require extensive resources and extended timeframes. The recovery phase includes activities taken to assess, manage, and coordinate the recovery that includes the following:

  • IC will call for deactivation and determine when the facility can return to normal operations.  
  • An employee support system must be established.  Human resources will coordinate in-house/outside referrals to employee assistance programs  
  • Inventory for Damage and Loss will be completed. One copy will be kept by the Chief Financial Officer (CFO) and another with the business office.     
  • The Chief Financial Officer will account for disaster related expenses.
  • Additional documentation may include: property damage, direct operating cost, consequential loss, damaged or destroyed equipment, and construction related expenses.
  • After Action Report (AAR) to be completed within 60-days

After Action Report

The AAR is a vital opportunity to evaluate emergency response efficacy. A cross-sectional group of staff who participated in an event will be encouraged to participate in the AAR. The AAR will consist of a thorough investigation and analysis of procedural proficiency of the emergency response. The goal of the AAR is to have a transparent evaluation of the procedural steps executed in the Emergency Preparedness Plan that enhances facility readiness for future events.  

This EPP outline serves as a foundation to create a more individualized plan case specific to different types of long term care operations.  Each long term care operation varies in its complexity, geographic region, and level of community involvement for coordinated emergency drills: It’s essential to review and analyze the CMS Rule to focus on the elements that help customize a plan specific to individual long term care providers. The references to FEMA, NIMS, and ICS are the antecedents that should guide plan development to satisfy Medicare conditions-of-participation. Get started. Keep it simple. Good luck.    

Jaime Todd, MBA, LNHA, is a health care reorganization/turnaround executive specializing in acute care, behavioral and mental health, primary care, and long term care. Todd is a widely published author of leadership, licensing/regulatory compliance, risk management, and health care operational management articles. He can be reached at jtandarlene@outlook.com.


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