VNAA Summary of Medicare/Medicaid Emergency Preparedness Proposed Rule On December 27, the Centers for Medicare and Medicaid (CMS) proposed new regulations that would require virtually every type of Medicare and Medicaid participating provider (other than individual practitioners) to develop and implement comprehensive emergency preparedness programs as part of the Conditions of Participation (COP). Electronic comments are due no later than 5 p.m. on February 25, 2014 to http://www.regulations.gov. The proposed rules require: An all risks assessment; A comprehensive plan to address those risks along with periodic plan updates; Policies and procedures to implement that plan Ongoing training of all staff, Communications plans and systems to maintain contact with staff and patients, and Training and staff drills to implement and test the plan. CMS developed this proposed rule by identifying the new conditions required for hospitals and then applying the very similar rules with some subtractions or additions for each provider type. There are separate rules laid out for home health agencies and rules for hospices in the proposed rule as well as additional rules for hospices with inpatient facilities. The proposed rule suggests that to understand the rule fully, one should both familiarize oneself with the regulations specific for your provider type, but also be familiar with all explanatory material for the hospital COPs. The rules also make clear that any contractors employed by providers are subject to the provider s emergency plan. CMS estimates that it will only take a home health agency 26 hours at $1,424 to develop its comprehensive risk assessment and emergency preparedness plan and about 80 hours total to do everything listed in the regulation. There is no additional funding forthcoming from CMS. CMS is requesting comments on these proposed rules, specifically: Whether they should be phased-in, tested and perfected on a couple provider types first; The need for two annual test/drills and Ideas on integration with any and all other requirements and plans already in place. CMS encourages the adoption of a well thought-out, cohesive system of response both within and across provider types.
Note on New Requirements CMS organizes the requirement for each type of provider into four areas: 1. Risk assessment and planning 2. Policies and procedures 3. Communication 4. Training and testing Please note that while the requirements for home health and hospices are very similar, there are differences and some of which are clearly intentional, while others may be unintentional artifacts of the writing and editing process. CMS also notes that some disaster preparedness activity is already in the hospice conditions but not in home health conditions. Hospices that include inpatient facilities will need to meet additional conditions related to inpatients facilities. Special conditions for hospices with inpatient facilities are in the hospice summary. With regard to home health, CMS asserts that Joint Commission on Accreditation of Health Care Organizations (JCAHO) accredited home health agencies already must comply with standards related to emergency preparedness and will thus have a somewhat lower burden in complying with these additional standards. New Requirements Proposed for Home Health Agencies The home health agency (HHA) must comply with all applicable Federal and State emergency preparedness requirements. The HHA must establish and maintain an emergency preparedness program that meets the requirements below which must include but is not limited the elements below. Risk Assessment and Planning Agencies must develop and maintain an emergency preparedness plan, review and update it at least annually. The plan must be based on and include a documented facility-based and community-based assessment using an all hazards approach. The plan must include strategies addressing emergency events from the risk assessment. The plan must address the patient population including but not limited to the types of services the agency can provide in an emergency, continuity of operations including delegations of authority and succession plans. The plan must include a process for cooperation and collaboration with local, tribal, regional, state and federal emergency preparedness officials efforts to ensure a integrated approach to a disaster including documentation of the agency s efforts to contact such officials and, when applicable, participation in collaborative and cooperative planning efforts. Page 2 of 7
Policies and Procedures Agencies must develop and implement, review and update annually emergency preparedness policies and procedures based on the plan, risk assessment, and communication plan. The policies and procedures must address at a minimum: Plans for patients during a disaster and individual plans must be included in each patient s comprehensive patient assessment. Procedures to inform state and local emergency preparedness officials about patients in need of evacuation from their residences at any time due to an emergency situation based on the patient s medical and psychiatric condition and home environment. A system to track the location of staff and patients both during and after the emergency. A system of medical documentation that preserves information, confidentiality is secure and readily available. The use of volunteers or other emergency staffing strategies including state or federally designated health care professionals to address surge needs during an emergency. The development of arrangements with other HHAs or providers to receive patients in the event of limitations or cessation of operations to assure continuity of patient services. Communication Agencies must develop and maintain, review and update annually an emergency communications plan that complies with federal and state law. It must contain all of the following: Name and contact information for staff, entities providing services under arrangement, patient physicians, other HHAs, volunteers. Contact information for federal, state, tribal, regional, or local emergency preparedness staff and other sources of assistance. Primary and alternative means for communication with HHA staff, federal, state, tribal, regional and local emergency management agencies. Method of sharing information and medical documentation for patients under care and as necessary with other health care providers to assure continuity of care. Means of providing information about the patients general condition and location as permitted under HIPAA. Means of providing information about the HHA s needs and its ability to provide assistance to the authority having jurisdiction, incident command center or designee. Training and Testing Agencies must develop and maintain, review and update annually an emergency preparedness training and testing program that must include: Page 3 of 7
Initial training in emergency preparedness policies and procedures to new and existing staff, individuals providing services under arrangement, volunteers, consistent with their expected roles. Provide preparedness training at least annually. Maintain documentation the training. Ensure that all staff can demonstrate knowledge of emergency procedures. Conduct drills and exercises to test the plan including participation in a community mock disaster drill at least annually or facility-based drill if community-based not available (subject to one year exception if disaster plan actually implemented). Conduct a paper-based, tabletop exercise at least annually. o A tabletop exercise is a group discussion led by a facilitator using a narrated, clinically relevant emergency scenario and a set of problem statement, directed messages or prepared questions designed to challenge an emergency plan. Analyze the HHA s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the plan as needed. New Requirements Proposed for Hospices Hospices must comply with all applicable Federal and State emergency preparedness requirements. The hospice must establish and maintain an emergency preparedness program that meets the requirements below which must include but is not limited the elements below. Risk Assessment and Planning The hospice must develop and maintain an emergency preparedness plan, review and update it at least annually. The plan must be based on and include a documented facility-based and community based assessment using an all hazards approach. The plan must include strategies addressing emergency events from the risk assessment, including the management of the consequences of power failures natural disasters and other emergencies that would affect the hospice s ability to provide care. The plan must address the patient population including but not limited to the types of services the hospice can provide in an emergency, continuity of operations including delegations of authority and succession plans. The plan must include a process for cooperation and collaboration with local, tribal, regional, state and federal emergency preparedness officials efforts to ensure an integrated approach to a disaster including documentation of the agency s efforts to contact such officials and, when applicable, participation in collaborative and cooperative planning efforts. Policies and Procedures Hospices must develop and implement, review and update annually emergency preparedness policies and procedures based on the plan, risk assessment, and communication plan. The policies and procedures must address at a minimum: Page 4 of 7
A system to track the location of hospice employees and patients in the hospice s care both during and after the emergency. Procedures to inform state and local emergency preparedness officials about patients in need of evacuation from their residences at any time due to an emergency situation based on the patient s medical and psychiatric condition and home environment. A system of medical documentation that preserves patient information, confidentiality, is secure and readily available. The use of hospice employees in an emergency and other emergency staffing strategies including the process and role for integration of state and federally designated health care professionals to address surge needs during an emergency. The development of arrangements with other hospices or providers to receive patients in the event of limitations or cessation of operations to assure continuity of patient services. For hospice operating inpatient facilities only, the policies and procedures must also address: A means to shelter in place for patients and hospice employees who remain in the hospice. Safe evacuation from the hospice which includes consideration of care and treatment needs of evacuees, staff responsibilities, transportation, identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance. Provision of subsistence needs for hospice employees and patients whether they evacuate or shelter in place which include but are not limited to: food, water, shelter, alternative sources of energy to maintain temperatures to protect the health and safety as well as safe and sanitary storage of provisions, emergency lighting, fire detection/extinguishing/alarm systems, sewage and waste disposal. The role of the hospice under a waiver declared by the secretary under section 1135 of the Act providing for the care and treatment at an alternative café site identified by emergency management officials. Communication Hospices must develop and maintain, review and update annually an emergency communications plan that complies with federal and state law. It must contain all of the following: Name and contact information for hospice employees, entities providing services under arrangement, patients physicians, other hospices. Contact information for federal, state, tribal, regional, or local emergency preparedness staff and other sources of assistance. Primary and alternative means for communication with hospice employees, federal, state, tribal, regional, and local emergency management agencies. Method of sharing information and medical documentation for patients under hospice care and as necessary with other health care providers to assure continuity of care. Means, in case of evacuation, to release information as permitted under HIPAA. Page 5 of 7
Means of providing information about the hospice s inpatient occupancy, needs and its ability to provide assistance to the authority having jurisdiction, incident command center or designee. Training and Testing Hospices must develop and maintain, review and update annually an emergency preparedness training and testing program that must include: Initial training in emergency preparedness policies and procedures to new and existing hospice employees and individuals providing services under arrangement consistent with their expected roles. Ensure that all staff can demonstrate knowledge of emergency procedures. Provide emergency preparedness training at least annually; 4. Periodically review and rehearse the emergency preparedness plan with hospice employees (including nonemployee staff with special emphasis on carrying out the procedures necessary to protect the patients and others. Maintain documentation of all emergency preparedness training. Conduct drills and exercises to test the plan including participation in a community mock disaster drill at least annually or facility-based drill if community-based not available (subject to 1 year exception if disaster plan actually implemented). Conduct a paper-based, tabletop exercise at least annually. o A tabletop exercise is a group discussion led by a facilitator using a narrated, clinically relevant emergency scenario and a set of problem statement, directed messages or prepared questions designed to challenge an emergency plan. Analyze the hospice s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the plan as needed. Additional Clarification of Requirements Based on the Regulatory Preamble What does the required all hazards risk assessment approach to the emergency preparedness requirement include? The proposed rule indicates it is imperative that hospitals perform an all-hazards risk assessment consistent with concepts outlined in the National Preparedness Guidelines published by the U.S. Department of Homeland Security. CMS encourages hospitals in adjoining states to work together to formulate plans to provide services across state lines in the event of a natural or man-made disaster to ensure continuity of care during a disaster. What are the four phases of emergency management that to consider? CMS specifically cites: 1. Mitigation activities to lessen the severity and impact of a potential disaster or emergency might have on health facility operations. Page 6 of 7
2. Preparedness activities to build capacity and identify resources that may be used should a disaster or emergency occur. 3. Response to the actual emergency and control the negative effects of the emergency situation. 4. Recovery that begins almost concurrently with response activities and directed at restoring essential services and resuming normal operations to sustain the long-term viability of the health facility. Given the requirement for community-wide collaboration and coordination of emergency preparedness plans, what entity is in the best position to facilitate this coordination? CMS asserts that since hospitals are the focal points for health care in their respective communities hospitals are in the best position to coordinate emergency preparedness planning with other providers and suppliers in their communities. What does CMS do to accommodate the special situations faced by rural providers? CMS acknowledges that rural communities face challenges in emergency preparedness and cites studies that document some of the challenges and limitations but makes no special accommodations for rural facilities. How does CMS address the cost of emergency preparedness? CMS notes that have and continue to be sources of grant funding to state and local governments dedicated to funding emergency preparedness activities. In addition, as noted above, CMS projects relatively modest start-up costs at the provider level and balances these costs against the potential savings in dollars and lives that will result from effective disaster preparedness. Does CMS offer specific guidance in meeting these regulations? CMS makes multiple references to government and private reports and websites throughout the preamble to the regulation that it suggests will provide more resources and guidance to providers in meeting many of the required conditions. It does not include templates or model plans or procedures that would facilitate this process. It assumes each provider will find its own route to compliance. Page 7 of 7