CMS Emergency Preparedness Training Deadline is Here, Are you Ready?

The assumption is that all the accrediting organizations and CMS will be looking more deeply at Emergency Management standards starting this November.

• By John M. Eliszewski
• Nov 01, 2017

On Sept. 16, 2016, the Centers for Medicare & Medicaid Services (CMS) issued a final rule instituting new emergency preparedness requirements for health care facilities that participate in the Medicare and Medicaid programs. The implementation date for the Conditions of Participation (CoP) requirement is Nov. 15, 2017. The new regulations apply to 17 provider types, including hospitals, critical access hospitals (CAH), ambulatory surgical centers, and long-term care facilities.

This rule establishes national emergency preparedness requirements that include adequately planning for disasters that fall on a continuum between disruptive to disastrous. Also, organizations must define their response to emergencies and how they will collaborate and coordinate with federal, state, tribal, regional, and local emergency preparedness systems. The bottom line is health care facilities must develop a comprehensive Emergency Operations Plan (EOP) that will meet the needs of patients, the community, and their staff during disasters and emergency situations.

Of the three hospital accrediting agencies, The Joint Commission (TJC), Healthcare Facilities Accreditation Program (HFAP), and Det Norske Veritas, Inc. (DNV), TJC accounts for approximately 80 percent of the health care accreditations and certifications. The CoPs state that a hospital that is compliant with TJC standards should be mostly compliant with CMS standards. The assumption is that all the accrediting organizations and CMS will be looking more deeply at Emergency Management (EM) standards starting this November. Looking at TJC’s inspection data of most cited standards for EM for 2016, the top five were:

1. EM.03.01.03 -- Evaluate the effectiveness of the Emergency Operations Plan (EOP)
Two drills annually, activating the EOP at each site (not just the flagship)

2. EM.02.02.13 -- Granting disaster privileges to Licensed Independent Practitioners

3. EM.01.01.01 -- Foundation
Inventory of resources and assets, conducting Hazard Vulnerability Assessments (HVA), Leaders and medical staff participate in HVA

4. EM.03.01.01 -- Evaluations
Annual review of inventory, EOP, and HVA

5. EM.02.01.01 -- EOP Requirement
Identify 96-hour capabilities; leaders’ participation in developing, maintaining, and updating the EOP as necessary; and process for initiating and terminating response recovery

At a high level, the final rule requires health care facilities to conduct risk assessments using an all-hazards approach; develop emergency preparedness plans, policies, and procedures; create distinct communications plans; and establish training and testing programs.

It Starts With the Risk Assessment
Health care facilities are required to conduct risk assessments utilizing an all-hazards approach to develop and maintain a comprehensive emergency preparedness program. The definition of all-hazards approach is an integrated approach to emergency preparedness that focuses on hazard identification and developing emergency preparedness capacities and capabilities that can address those, as well as a wide spectrum of emergencies or disasters. They must recognize potential hazards, threats and events, and assess their impact on the care, treatment, and services they provide for patients. The health care facility must collaborate with its community partners and prioritize the potential emergencies that have been identified by its risk assessment. The health care organization utilizes the risk assessment analysis as grounds for prioritizing its mitigation activities.

Required Elements of an Emergency Operations Plan
The EOP must include eight elements for hospitals and seven elements for CAHs. The main difference is that CAHs do not have Transplant Centers. Also, CAHs have additional training requirements centered on fire safety, which was specifically mentioned by CMS in the final rule remarks. The elements are listed below:

• Emergency plan
• Policies and procedures
• Communication plan
• Training and testing
• Emergency and Standby Power Systems
• Integrated Health care Systems (optional)
• Transplant Hospitals (if applicable)
• Reference Standards

CMS expressed concerns over the lack of consistency when it came to collaboration between CAHs and their local fire departments and fire marshals. CMS's intent is to increase the level of initial staff training to be able to appropriately respond to a fire at their facilities. Initial training requirements are:

• Prompt reporting and extinguishing of fires
• Protection and or evacuation of patients, visitors, and staff
• Fire prevention
• Cooperation and collaboration with firefighting and disaster authorities

Communication Plan
Communication issues are one of the most identified problem areas of any emergency drill or event. That is why a communication plan is critical to the success of all emergency plans. Health care organizations must develop and maintain a communication plan that is reviewed and updated annually and includes names and contact information for staff, physicians, and volunteers. There should be a succession plan in place that identifies whom to contact when someone in the organization is not available during an emergency event. The names and contact information for federal, state, tribal, regional, and local emergency preparedness staff and means for communicating with these organizations must be included in the plan. The communication plan also must identify the method for sharing medical documentation, how patient information would be released in the event of an evacuation, and means for providing information regarding authorities having jurisdiction about occupancy, needs, and ability to provide assistance.

Training and Testing
Each organization is required to develop and maintain training and testing programs that are reviewed annually. Organizations must base their training on the EOP, risk assessment, policies and procedures and their communication plan.

The emergency preparedness training program must include initial training on emergency preparedness policies and procedures for all new and existing staff, contractors providing services, and volunteers consistent with their roles within the organization. The training must be conducted at least annually, and training records must be documented and maintained.

Annual testing of the emergency plan exercise must be a full-scale exercise that is community based or, depending on availability of the community groups, may be just facility based. Health care organizations are required to document who the contact was and why the community groups were not available for the exercise. Two exercises are required each year, one community-based, individual-based, or it could be a tabletop exercise.

A tabletop exercise involves key personnel discussing simulated scenarios in an informal setting. A tabletop exercise is a discussion-based exercise that involves senior staff, elected or appointed officials, and other key decision-making personnel in a group discussion centered on a hypothetical scenario. Tabletop exercises can be used to assess plans, policies, and procedures without deploying resources.

If an actual natural or man-made emergency situation that requires the activation of the emergency plan occurs, the health care organization is exempt for one year following the event from having to conduct training exercises.

The TJC standards do not currently allow for tabletop exercises to count toward one of their two mandated training exercises. This is one of the topics that is under the TJC gap analysis review process. A TJC accredited organization is required to conduct two full-scale exercises by the Nov. 15 deadline.

CMS has provided some examples that health care organizations could use for their tabletop or full-scale, community -based exercises. Some examples to consider are:

• Earthquakes
• Tornadoes
• Hurricane
• Flooding
• Fires
• Cybersecurity attack
• Single-facility disaster (power outage)
• Medical surge (i.e., community disaster leading to influx of patients)
• Infectious disease outbreak
• Active shooter

Regardless of the type of drill or actual emergency, the response to the event must be analyzed. Documentation of all drills, tabletop exercises, and actual emergency events must be maintained. Then, organizations must go back to their emergency plan and make adjustments based on feedback received.

What's Next?
All organizations will need to conduct a comprehensive review of the current state of their emergency preparedness training program to identify next steps required to be in compliance with the final rule. Trade associations can help you stay informed and aware of standard changes. Networking with other health care organizations and building strong partnerships with contractors and vendors are very beneficial.

It has long been understood that the health care industry is one of the most—if not the most—regulated industry in the United States. For most hospitals, many of the basic requirements of this final rule are currently implemented but need to be assessed and modified for compliance. For some health care organizations, it will require additional time and resources to get their facilities up to par with this rule. There are plenty of resources to assist with compliance. CMS, TJC, American Society of Healthcare Engineers (ASHE), and other consulting networks have a wealth of information to aid in assessing your emergency preparedness training program to make sure you are ready for Nov. 15!

This article originally appeared in the November 2017 issue of Occupational Health & Safety.