HOME HEALTH CoP SUCCESS GUIDE: EMERGENCY

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August 2017HOME HEALTH CoP SUCCESS GUIDE:EMERGENCY PREPAREDNESSCopyright 2017 HEALTHCAREfirst. All rights reserved. 8/1/2017

2 Home Health CoP Success Guide: Emergency PreparednessINTRODUCTIONINTRODUCTIONThe Centers for Medicare and Medicaid Services (CMS) released an advance copy ofinterpretive guidelines and survey procedures that surveyors will use to determine whetherhome health agencies have successfully adopted the federal Emergency PreparednessConditions of Participation (CoP). When evaluating for compliance with the EmergencyPreparedness CoP requirements, surveyors will follow standard survey protocols duringinitial, revalidation, recertification, and complaint surveys. CMS’ goal in enforcement of theserequirements is to ensure that Medicare certified organizations “better anticipate and plan forneeds, rapidly respond as a facility, as well as integrate with local public health and emergencymanagement agencies and healthcare coalitions’ response activities and rapidly recoverfollowing the disaster.”This guide offers insight into what evidence home health agencies must be prepared toprovide to demonstrate compliance with the CoP at 484.22 beginning on November 15,2017. The advance copy of the CMS Emergency Preparedness Guidance to Surveyorscan be found at: ads/Survey-and-Cert-Letter-17-29.pdf.

3 Home Health CoP Success Guide: Emergency PreparednessSURVEY PREPARATIONSURVEY PREPARATIONE-0001: Emergency Preparedness ProgramThe HHA must comply with all applicable Federal, State and local emergency preparednessrequirements and establish and maintain a comprehensive emergency preparedness programthat includes all required elements. Evidence that: Administrative staff are able to verify that an emergency preparedness program is in placeWritten evidence of the program can be producedThe program is based on a relevant all-hazards assessment (e.g. natural, man-made, facility,geographic, etc.)All required elements are included as found in E-tags belowThe program describes a comprehensive approach to meeting the health, safety, andsecurity needs of their staff and patient population during an emergency or disastersituation.The program addresses means to coordinate with other healthcare facilities, and thecommunityThe program is reviewed and updated annually (e.g. date of reviews and updates)E-0004: Emergency Preparedness PlanThe emergency preparedness program includes an emergency preparedness plan that mustbe reviewed and updated at least annually. Evidence that: An emergency preparedness plan is in place and a copy can be producedAgency leadership can indicate how the hazard risk assessment was conductedAll required elements are included as found in E-tags belowCollaboration with local emergency preparedness officials is evidentThe plan includes the likely durations of interruptions and arrangements to ameliorateinterruptionsDocumentation exists that demonstrates that the plan is reviewed and updated annually

4 Home Health CoP Success Guide: Emergency PreparednessSURVEY PREPARATIONE-0006: Emergency Preparedness Plan BasisThe emergency plan is based on a documented, facility-based and community-basedrisk assessment, utilizing an all-hazards approach and includes strategies for addressingemergency events identified by the risk assessment. Evidence that: A facility-based, community-based risk assessment using an all-hazards approach wasconducted and can be proven via written documentsThe plan's “all-hazards” assessment includes, but is not limited to: natural, man-madedisasters and facility-based disasters that include care-related emergencies; equipmentand utility failures, including but not limited to interruptions in power, interruptions incommunication, loss of all or portion of a facility and interruptions to the normal supply ofessential resources, such as water, food, fuel, medications and medical supplies and gasesStrategies for addressing emergency events were identified by the risk assessmentThe patient population, types of services, and HHA’s ability to provide services during anemergency are includedWritten individual plans for each patient were included as part of the comprehensivepatient assessment and may be as simple as a detailed emergency card to be kept with thepatient)Plans include potential disasters that the patient may face within the home such as firehazards, flooding, and tornadosInformation as to how and when a patient is to contact local emergency officials has beendeterminedIntegrated planning with state and local entities has been undertakenE-0007: Emergency Preparedness Plan Patient Population and ServicesThe plan address patient/client population, including, but not limited to, persons at-risk; thetype of services the [facility] has the ability to provide in an emergency; and continuity ofoperations, including delegations of authority and succession plans. Evidence that: Continuity of operations, including delegations of authority and succession plans, wereestablishedDetermination was made as to the patient populations that would be at risk during anemergency event

5 Home Health CoP Success Guide: Emergency PreparednessSURVEY PREPARATION Planning considers elements such as: essential personnel, essential functions, criticalresources, vital records and IT data protection, alternate facility identification and location,and financial resourcesStrategies are in place to address the needs of at risk or vulnerable patientsServices are identified that the facility should be able to provide during an emergencyPlans to continue operations during an emergency are detailedStaff and the specific roles they will assume are identifiedDelegations of authority and succession plans are in placeProcedures are identified to follow up with on-duty staff and patients to determine servicesthat are needed in the event that there is an interruption in servicesThe use of volunteers in an emergency or other emergency staffing strategies have beenaddressedWays to integrate with State or Federally designated health care professionals to addresssurge needs during an emergency have been identifiedResources from various agencies such as the Federal Emergency ManagementAdministration (FEMA) and Assistant Secretary for Preparedness and Response (ASPR) areutilized, as appropriate, when developing strategies for ensuring continuity of operationsE-0009: CollaborationInclude a process for cooperation and collaboration with local, tribal, regional, State, andFederal emergency preparedness officials' efforts to maintain an integrated response duringa disaster or emergency situation, including documentation of the facility's efforts to contactsuch officials and, when applicable, of its participation in collaborative and cooperativeplanning efforts. Evidence that: A process for cooperation and collaboration with existing local, tribal, regional, State, andFederal resources was establishedEfforts to contact such officials are documentedProcedures are in place to inform State and local emergency preparedness officials aboutpatients in need of evacuation from their residences at any time due to an emergencysituation based on the patient's medical and psychiatric condition and home environmentProcedures are in place to identify and inform State and local officials of any on-duty staffor patients that they are unable to contact

6 Home Health CoP Success Guide: Emergency PreparednessSURVEY PREPARATIONE-0013: Polices and ProceduresThe HHA must develop and implement emergency preparedness policies and procedures,based on the emergency plan set, risk assessment, and the communication plan. The policiesand procedures must be reviewed and updated at least annually. Evidence that: Written emergency preparedness policies and procedures have been created and areaccessiblePolicies and procedures were developed based on the facility and community based riskassessment and address the disaster assessment utilizing an all-hazards approachPolicies and procedures include details of the communication planPolicies and procedures address training and testingPolicies and procedures have been reviewed and updated on an annual basisE-0017: Individual PlansThe plans for the HHA’s patients during a natural or man-made disaster. Individual plans foreach patient must be included as part of the comprehensive patient assessment, which mustbe conducted according to the provisions at §484.55. Evidence that: Discussions have taken place to develop individualized patient emergency preparednessplans based on potential disasters patients may face (e.g. fire hazard, loss or power,flooding, etc.)These discussions are documentedPersons involved in the clinical care (i.e. patient representatives, caregivers) are educatedon steps that can be taken for patient safetyEach patient has an individualized emergency plan documented as part of the patient’scomprehensive assessmentIndividualized emergency plans are in writing (e.g. could be as simple as a detailedemergency card to be kept with the patient)A copy of the individualized emergency plan in the patient’s fileA copy to the individualized emergency plan is provided to the patient and or caregiver

7 Home Health CoP Success Guide: Emergency PreparednessSURVEY PREPARATIONE-0019: State and Local NotificationProcedures to inform State and local emergency preparedness officials about homeboundpatients in need of evacuation from their residences at any time due to an emergency situationbased on the patient’s medical and psychiatric condition and home environment are in place.Evidence that: The emergency plan includes procedures to inform State and local emergencypreparedness officials about patients in need of evacuation from their residencesState and local emergency preparedness officials have been informed of the need forpatient evacuations and the clinical care needed for the patientsClinical information includes but is not limited to: level of mobility, medications needs,type of life-saving equipment required, if life-saving equipment able to be transported, anyspecial need (e.g. communication challenges, language barriers, intellectual disabilities,special dietary needs, etc.)Health information is protected according to HIPAA requirementsConsideration has been given to patient choiceProcedures are in compliance with State and local laws and consideration of applicablecommunity practicesE-0021: Interruption of ServicesThe plan includes procedures to follow up with on-duty staff and patients to determineservices that are needed, in the event that there is an interruption in services during, or due to,an emergency. The HHA must inform State and local officials of any on-duty staff or patientsthat they are unable to contact. Evidence that: Triage procedures for identification of a need to interrupt services during an emergency areincluded in the planPlans include procedures for notification of all employees, contractors and patients in theevent of interruption of servicesThe plan includes procedures to follow up with on-duty staff and patients to determine theservices that are neededMechanisms to inform State and local officials of any on-duty staff or patients that they areunable to contact are in place and usedThe plan has been followed during any actual emergencies

8 Home Health CoP Success Guide: Emergency PreparednessSURVEY PREPARATIONE-0024: VolunteersThe use of volunteers in an emergency or other emergency staffing strategies, including theprocess and role for integration of State and Federally designated health care professionals toaddress surge needs during an emergency. Evidence that: Policies and procedures for the use of volunteers, and other staffing strategies related tosurge in its emergency plan, have been developedCommunication with designated community health care professionals (as applicable) canbe demonstratedE-0029: Emergency Preparedness Communication PlanAn emergency preparedness communication plan that complies with Federal, State and locallaws must be created and reviewed and updated at least annually. Evidence that: The written communication plan can be producedThe communication plan is reviewed and updated annuallyE-0030: Emergency Preparedness Communication Plan Contact InformationThe communication plan includes the names and contact information for: staff, entitiesproviding services under arrangement, patients' physicians, other facilities, volunteers.Evidence that: Contact information for all individuals and entities is available and updated throughout theyearOther facilities that have been identified as resources in the event of an emergencyContact information has been reviewed and updated at least annuallyContact information is readily available and accessible to leadership and staff during anemergencyIf electronic data storage for this information is used, there is data back-up with hardcopies or demonstrate capability to reproduce contact lists and access this data duringemergencies

9 Home Health CoP Success Guide: Emergency PreparednessSURVEY PREPARATIONE-0031: Emergency Preparedness Communication Plan Contact InformationThe communication plan includes contact information for the following: Federal, State, tribal,regional, and local emergency preparedness staff and other sources of assistance. Evidencethat: A list of the contacts, with their contact information, is availableThe contact information has been reviewed and updated at least annuallyContact information is readily available and accessible to leadership during an emergencyIf electronic data storage for this information is used, there is data back-up with hardcopies or demonstrate capability to reproduce contact lists and access this data duringemergenciesE-0032: Emergency Preparedness Communication Plan Means of CommunicationThe communication plan addresses primary and alternate means for communicating withthe staff, Federal, State, tribal, regional, and local emergency management agencies exist.Evidence that: The primary and alternate means for communicating with facility staff, Federal, State, tribal,regional and local emergency management agencies have been identifiedThe following alternate means of communication have been considered and addressed:pagers, cellular telephones, radio transceivers (that is, walkie-talkies), and various otherradio devices such as the NOAA Weather Radio and Amateur Radio Operators’ (HAM Radio)systems, satellite telephone communications systems and should include issues withcellular phones, State and local emergency use of communication systems (e.g. SHAredRESources (SHARES) High Frequency (HF), Radio Amateur Civil Emergency Services (RACES),National Communication System (NCS), National Security and Emergency Preparednesscommunications services, the Government Emergency Telecommunications Services(GETS), the Telecommunications Service Priority (TSP) Program, Wireless Priority Service(WPS), and SHARES, satellite phones, radio, and short wave radio.Communications equipment or communication systems listed in the plan can be verifiedThe plan is reviewed and updated at least annually

10 Home Health CoP Success Guide: Emergency PreparednessSURVEY PREPARATIONE-0033: Emergency Preparedness Communication Plan Sharing of InformationThe communication plan includes a means of providing information about the generalcondition and location of patients under care and a method for sharing information andmedical documentation for patients under care, as necessary, with other health providers tomaintain the continuity of care. Evidence that: The communication plan includes a method for sharing information and medicaldocumentation for patients under the facility's care, as necessary, with other healthprovidersPolicies and procedures that address the means that will be used to release patientinformation that include the general condition and location of patients are writtenThe system ensures that the information released is timely, accurate and available to familymembersHIPAA requirements are met in consideration of disclosure exceptions during emergenciesPatients are given the opportunity to agree to or to object to disclosureE-0034: Occupancy, Needs, and Ability to Provide AssistanceA means of providing information about the occupancy, needs, and its ability to provideassistance, to the authority having jurisdiction, the Incident Command Center, or designee.Evidence that: Plans are in place for communication of agency needs, and any agency assistancecapabilities, with community emergency resourcesOccupancy reporting considers, but is not limited to, reporting the number of patientscurrently receiving treatment and considers patient acuity, high tech needs, frequency ofvisits, etc.Agency capacity is included in the considerationAgency needs, such as road conditions, access to fuel, assistance with evacuation andtransfers, etc. are addressed

11 Home Health CoP Success Guide: Emergency PreparednessSURVEY PREPARATIONE-0036: Training and TestingThe HHA must develop and maintain an emergency preparedness training and testing programthat is based on the emergency plan and the program must be reviewed and updated at leastannually. Evidence that: A written training and testing program that includes instruction to ensure that allindividuals are aware of the agency program is in placeTraining includes education and instruction to staff, contractors, and facility volunteersabout program contentTesting is in place to evaluate the effectiveness of the training and the overall emergencypreparedness programTesting includes conducting drills and/or exercises to test the emergency plan to identifygaps and areas for improvementThe program meets the requirements of the regulation (as detailed below)Documentation can be produced to demonstrate that the program has been reviewed andupdated on, at least, an annual basisThe training and testing program reflects the risks identified in the facility’s risk assessmentTraining/testing include information on how the HHA willCommunicate the facility closure to required individuals and agenciesTesting patient tracking systems and testing transportation procedures for safely movingpatients (if indicated)Multiple location agency training and testing program reflect the risk assessment for eachspecific locationThe training and testing programs are reviewed and updated at least annuallyE-0037: Training ProgramThe HHA must include all of the following: Initial training in emergency preparedness policiesand procedures to all new and existing staff, individuals providing services under arrangement,and volunteers, consistent with their expected role; provide emergency preparedness trainingat least annually; maintain documentation of all emergency preparedness training. Evidencethat: Initial emergency preparedness training and annual emergency preparedness trainingofferings are in place and provided to allTraining documentation includes the specific training completed and methods used fordemonstrating knowledge of the training program for all individuals

12 Home Health CoP Success Guide: Emergency PreparednessSURVEY PREPARATION Training is consistent with the individual’s role within the agency and during emergenciesInitial emergency training during orientation (or shortly thereafter) is provided to ensureinitial training is not delayed.Agencies with multiple locations ensure training is relevant to the specific location andwhen staff are assigned to a new locationStaff knowledge of emergency procedures can be verified upon interviewTraining files verify that all staff, contractors, volunteers have received initial and annualemergency preparedness trainingAnnual training is modified each year, as appropriate, to incorporating any lessons learnedfrom th

The program addresses means to coordinate with other healthcare facilities, and the community The program is reviewed and updated annually (e.g. date of reviews and updates) E-0004: Emergency Preparedness Plan The emergency preparedness program includes an emergency preparedness plan tha