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Texas State of Emergency- Successful implementation of the new Emergency Preparedness CoP is crucial.

The recent photograph of nursing home residents sitting in waist deep water depicted the gravity of the current situation in Texas, which has shocked and concerned us all (TIME, 8/26/2017). Here at CHAP, we considered that these residents could have been our family members, our friends, our neighbors or patients of our CHAP accredited agencies. While we have been fortunate in not having been affected by this catastrophe, the widespread devastation has heightened our awareness of the need for all of our agencies to be prepared for any emergency.  Considering these recent events, let’s take this opportunity to revisit CMS’ condition of participation (CoP), Emergency Preparedness (EP), whose implementation date of 11/15/17 is fast approaching.

Emergency Preparedness: EP consists of 5 standards: (a) Emergency Plan, (b) Policies and Procedures, (c) Communication Plan, (d) Training and testing, and (e) Integrated healthcare systems which include several elements. As you review each standard and the elements within, ask yourself the following questions. Your answers to these simple questions will indicate your readiness to meet the requirements of the CoP and, more importantly, the needs of your patients, families and your community during any type of emergency. 

§ CFR 484.22

  1. Emergency Plan:
  2. Based on a risk assessment – Is your risk assessment facility-based and community-based? Does it use an all-hazards approach? 
  3. Strategies – What’s your strategy or strategies for handling the risks identified in your assessment? 
  4. Plans address the patient population – What’s your plan in continuing to provide your services and/or offer emergency care in an emergency?
  5. Policies and Procedures: Do you have policies and procedures reflecting your:
  6. Plans for HHA’s patients during a natural or man-made disaster which include individual patient plans
  7. Procedures on informing the State and local emergency preparedness officials about HHA patients in need of evacuation based on the patient’s medical and psychiatric condition and home environment
  8. Procedures in following up with on-duty staff and patients to determine services that are needed if there is an interruption in services
  9. System of medical documentation which preserves and protects confidentiality of patient information and maintains availability of records
  10. Use of volunteers in an emergency or other staffing strategies
  1.  Communication Plan: Does your communication plan include:
    1. Contact information for staff, entities providing services under agreement, patients’   physicians, volunteers
    2. Contact information for Federal, State, tribal, regional or local EP staff and other sources of assistance
    3. Primary and alternate means for communicating with HHA’s staff, Federal, State, tribal, regional, and local emergency management agencies
    4. Method for sharing information and medical documentation for patients under the HHA’s care, as necessary, with other health care providers
    5. Means of providing information about general condition and location of patients under the facility’s care
    6. Means of providing information about HHA’s needs and its ability to provide assistance
  1. Training and testingHave you developed an emergency preparedness training and testing program based on your emergency plan, risk assessment, policies and procedures and communication plan? You training must be completed before 11/15/17.
    1. Must have a training program – which includes all of the following:
      1. Initial training in EP policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
      2. Provide EP training at least annually.
      3. Maintain documentation of the training.
      4. Demonstrate staff knowledge of emergency procedures.

(2) Testing: Have you made plans on how you will conduct exercises to test the emergency plan at least annually? Do your plans include all of these elements? Your testing must be completed by 11/15/17.

(i)Participate in a full-scale exercise that is community-based or when a community based exercise is not accessible, an individual, facility-based. Have you done so already? Do you have documentation of these efforts?

(ii) Conduct an additional exercise that may include, but is not limited to the following: Have you thought about what your additional exercise would look like?

  1. A second full-scale exercise that is community-based or individual, facility based.
  2. A tabletop exercise that includes a group discussion led by 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.

(iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. Have you assigned or delegated this task to someone who will be maintaining documentation of these events?

  1. Integrated healthcare systems: If a HHA is part of a healthcare system consisting of multiple separately certified healthcare facilities that elects to have a unified and integrated emergency preparedness program, the HHA may choose to participate in the healthcare system’s coordinated EP program. If elected, the unified and integrated EP program must do all of the following: Is your agency part of a larger healthcare system electing to unify and integrate EP programs? If so, have you participated in meeting others in your healthcare system and has your group taken action? Do you have documentation of these efforts?
  2. Demonstrate that each separate certified facility with the system actively participated in the development of the unified and integrated EP program. Be developed and maintained in a manner that takes into account each separate certified facility’s unique circumstances, patient populations, and services offered. 
  3. Demonstrate that each separate certified facility is capable of actively using the unified and integrated emergency preparedness program and is in compliance with the program.
  4. Include a unified and integrated EP plan that meets requirements and is based on and includes the following:
    1. A documented community-based risk assessment, utilizing an all-hazards approach.
    2. A documented individual facility-based risk assessment for each separately certified facility within the health system, utilizing an all-hazards approach.
  5. Include integrated policies and procedures that meet the requirements, a coordinated communication plan and training and testing programs that meet requirements of CoP.