cms survey & certification emergency preparedness initiative

Following the devastating experiences by health care facilities during Hurricanes Katrina and Rita, the Centers for Medicare & Medicaid Services (CMS) Survey and Certification (S&C) Group established a series of internal working groups, with representatives from the CMS Central and Regional Offices, to develop updated emergency preparedness policies and procedures that effectively address S&C essential functions. The recommendations from the working groups are being integrated into the larger CMS and HHS national plans to provide preparation guidance for S&C essential business functions.

The emergency preparedness rule for Medicare Participating Providers and Suppliers was published September 16, 2016, and the implementation date was November 15, 2017. It applies to all Hospitals, Long Term Care Facilities, Critical Access Hospitals, and Rural Health Clinics.

*Compliance is required for Medicare participation.

There are four core elements of the Emergency Preparedness Program and element of the plan must be reviewed and updated annually.

RISK ASSESSMENT AND PLANNING – All providers must develop an emergency plan using all hazards approach, and plan and identify in advance essential functions and who is responsible in a crisis.

POLICIES AND PROCEDURES – These are developed based on the plan (e.g. medical documentation, evacuation or shelter and place).

COMMUNICATION PLAN – Establish alternate means of communication, provide information to local authorities sharing medical information, and provide occupancy information and assistance to other facilities in the community.

TRAINING AND TESTING PROGRAM – Train staff and test the plan through drills.

NOTICE ON TRAINING & EXERCISES

If a facility activates their emergency plan due to a disaster, the facility is exempt from one full-scale/individual based exercise for that year. However, the secondary requirement for a table-top exercise or exercise of choice still applies. Facilities must demonstrate completion of two exercises per annual year.

HAVE YOU TESTED?

The testing requirements include:

Participation in a full-scale exercise that is community-based, or when a community-based exercise is not accessible, an individual, facility-based exercise.

AND

Conduct an additional exercise that may include, but is not limited to the following:

• A second full-scale exercise that is individual, facility-based.
• A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.

IS THERE AN AFTER ACTION REPORT (AAR)? 

The AAR should document the exercise and next steps. Make it stand out with clear diagrams, lists of best practices, opportunities for improvement, and lists of resources. Make it readable and, most importantly, know where it is.

CMS wants you to “Demonstrate staff knowledge of emergency procedures.”

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Emergency-Prep-Rule.html

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Templates-Checklists.html

https://narhc.org/resources/rhc-rules-and-guidelines/#emergency