Hospitals are still moving to comply with the CMS Conditions of Participation (CoP) on emergency preparedness, which became effective in late 2016, and some are finding that the plans they had in place previously are not quite enough to meet the CMS expectations. During 2017, many hospitals will be reviewing and revising their emergency preparedness plans before CMS starts checking for compliance.The final rule on Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers went into effect on November 16, 2016, and healthcare providers and suppliers affected by the rule must comply and implement all regulations by November 16, 2017.
CMS says the purpose of the rule is to “establish national emergency preparedness requirements to ensure adequate planning for both natural and man-made disasters, and coordination with federal, state, tribal, regional and local emergency preparedness systems.” The requirements apply to all 17 provider and supplier types, and each has its own set of Emergency Preparedness regulations incorporated into its set of conditions or requirements for certification.
As a CoP, hospitals must be certain they are complying and not assume that pre-existing emergency plans will suffice. The final rule requires hospitals to meet four main standards:
- Based on a risk assessment of hazards likely in a geographic area, develop an emergency plan focusing on a full spectrum of potential emergencies or disasters identified for that specific location.
- Support the emergency plan by developing and implementing policies and procedures that address potential risks.
- Develop and maintain a communication plan that complies with federal, state, and local laws, across healthcare providers, working with public health departments and emergency management agencies.
- Develop initial training and testing programs, maintain the programs with at least annual trainings, and conduct drills and exercises or participate in an actual incident that tests the emergency plan.
One of the more significant requirements — and one that could be a challenge for some facilities — is for hospitals, critical access hospitals, and long-term care facilities to install and maintain emergency and standby power in accordance with CMS standards. CMS softened components of the rule after feedback from providers, removing the demand for additional hours of generator testing, adding more flexibility for a facility to to choose the type of exercise it conducts in the second year, and allowing a separately certified facility within a healthcare system to participate in an emergency preparedness program for the whole system.
The emergency preparedness Conditions of Participation are available online at: http://go.cms.gov/2jjHdBO. The requirements are in line with the The Joint Commision’s Emergency Management Standards, which focus on six areas for hospitals to demonstrate they have proper plans and response mechanisms to a disaster. During planned exercises, the organization monitors at least these six critical areas:
- communications, both internal and external to community care partners, state and federal agencies,
- supplies stocked at adequate levels and appropriate to hazard vulnerabilities,
- security that will enable normal hospital operations and protect staff and property,
- staff roles and responsibilities within a standard Hospital Incident Command Structure,
- utilities that enable self-sufficiency for as long as possible, with a goal of 96 hours, and
- clinical activity plans for maintaining care, supporting vulnerable populations, and using alternate standards of care.
Waste No Time Complying
Hospitals should address the four core elements of the CoP immediately, says Tener Goodwin Veenema, PHD, MPH, RN, FAAN, an associate professor at the Johns Hopkins School of Nursing in Baltimore. Veenema has served as senior consultant to the U.S. government for emergency preparedness, including work with the departments of Health and Human Services, Homeland Security, Veterans Affairs, the Administration for Children and Families, and, most recently, the Federal Emergency Management Agency. Many hospitals, especially larger facilities and academic teaching hospitals, will find that they at least have a good start with complying, but others may find that the remaining eight months isn’t much time if they don’t already have a good emergency preparedness plan, she says.
“The challenge is going to be for many of the smaller healthcare facilities that haven’t had the resources, the manpower, or the funds to address emergency preparedness in a meaningful way up to this point,” she says. “Chances are good that a healthcare facility already has some elements of this emergency preparedness rule in place. From there, you need to line that up with the four core elements of this rule and look for the gaps.”
Veenema says she supports the CMS effort to improve national preparedness, and the recognition that natural and man-made disasters threaten the ability of organizations and staff to maintain continuity of patient care services. The healthcare community has learned from recent disasters that facilities need more robust planning, she says, citing the 2012 experience of NYU Langone Medical Center during Hurricane Sandy in New York City. The hospital lost power and basements filled with water, destroying critical utilities and communications equipment. The hospital evacuated more than 300 patients, without the use of elevators.
NYU Langone has since modified its emergency plans and infrastructure. In addition to moving critical equipment out of the basement, the hospital installed a 12-foot-high steel storm barrier, altered drains and sewage lines to stop water backflow when streets flood, and installed steel doors in critical locations to hold back flood water.
“These healthcare facilities are really at risk of disruption in services from these types of events and there is a lot we can do to anticipate what damage might be done and to prevent or mitigate that damage,” Veenema says. “That’s why we need to encourage hospital administrators to plan for and finance these efforts proactively, as opposed to waiting until disaster or emergency occurs. We know that it costs far less to harden a facility prior to a disaster than the cost of rebuilding after.”
The first step for healthcare administrators is to understand the CMS CoP and the four main components, ensuring that all facets are incorporated into the emergency preparedness plan, Veenema says. She urges hospital leaders to pay special attention to the requirement for continuous and effective communication, which could be hindered in many emergencies and which could be the specific target of attacks.
“Last year, we saw a dramatic increase in cyberattacks on healthcare facilities, and there’s no reason to think that won’t continue,” she says. “The cyberattacks themselves can constitute an emergency if they threaten patient safety or disrupt communication, but they also can come in addition to a natural or man-made disaster. Healthcare facilities should anticipate and plan for those scenarios.”
Veenema notes that the rule requires communication to be well coordinated within the facility, with other healthcare providers, state and local public health departments, and state emergency management agencies. (See the story in this issue for more on communication strategies.)
“This heightened rule for communications recognizes that large-scale disaster events and public health emergencies, like a flu pandemic, will mobilize all members of the community. Not only the hospitals, but community clinics, physician offices, schools, businesses,” she says. “It’s going to involve everyone in the community, so communication will be a critical component of your emergency response.”
A good plan also will include extensive training for staff, along with testing and drills to reinforce the training while also looking for areas needing improvement, she says. Veenema notes that CMS included a significant amount of resources on its website for complying with the rule.
Hospital leaders can underestimate the need to focus on staff in emergency preparedness plans, Veenema cautions. Their need for preparation can be overlooked, she says.
“The one thing that, in my experience, hospitals never pay enough attention to is their most important asset, the people who come to work every day,” Veenema says. “A lot of national, state, and local emergency preparedness plans are founded on the assumption that healthcare professionals will know their roles and will know what to do during a disaster event. Studies have shown over and over that many providers do not possess the knowledge base required to be effective in these large-scale events that produce a surge in people needing care. It is critical for healthcare administrators to pay attention to education and training for their staff.”
Conduct a Risk Assessment
Others agree that some providers will be challenged to comply with the emergency preparedness CoP by the deadline. Timothy J. Fry, JD, an attorney with the law firm of McGuire Woods in Chicago, says hospitals should waste no time between now and the November deadline.
“To stay compliant, providers need to conduct a risk assessment, create and incorporate policies and procedures based on this risk assessment, develop a communication plan, and conduct training and testing to ensure the adequacy of the emergency preparedness program while maintaining documentation of the same for survey purposes,” Fry says. “Starting now is key.”
Hospitals, along with other inpatient provider types, may find the additional compliance burden of emergency fuel and generator testing to be particularly difficult and expensive, Fry says. Providing alternate sources of energy to maintain things like emergency lighting and fire detection in the face of an emergency also require revision of current facilities management, he says.
Overall, however, the requirement should not be entirely new for most healthcare facilities, because any well-managed facility has some type of emergency preparedness plan, Fry notes. That doesn’t mean the existing plan is sufficient, but it should at least provide a good start, he says.
“Many hospitals are already largely complying. For example, TJC requires an emergency operations plan and annual emergency training programs,” Fry says. “For such accredited hospitals, some review and updating may be necessary, but this can be accomplished through their annual review process. The rule’s burden falls much greater on hospitals without existing plans.”
Need Broad Community Connections
Even for facilities with good existing plans, there may be parts of the CMS requirement that are more likely to be missing.
“Certain aspects may be new, like the involvement of community providers or a wider consideration of potential emergencies, but many hospitals will find this fits with their emergency plans,” Fry says. “For those with existing plans, hospitals should make sure the scope does not involve the community only at certain locations or portions of their facility. The CMS rule will apply community considerations more broadly than past accreditation standards.”
The requirement for community-wide training may be the most challenging for many hospitals, says Hilary S. Blackwood, JD, also an attorney with McGuire Woods in Charlotte, NC. The community-based training is meant to simulate an anticipated response to an emergency involving actual operations and the community, and the practical considerations of making that happen could be daunting.
“Aside from the initial heavy lift of properly coordinating and conducting a risk assessment, the execution of the community-wide training seems likely to pose a challenge for many providers,” she says. “One of the two required trainings in most cases needs to be a full-scale exercise that is community-based. Some facilities may need to coordinate across state lines.”
Healthcare administrators can begin addressing that by first determining what the community already is doing for emergency preparedness and look for ways to get involved, Fry says.
For example, administrators might look into participating in a regional coalition’s work, or assisting with county health departments’ tests. Providers will need to consider how an emergency will affect the entire community. “In some regions, efforts already underway will fulfill the hospital’s obligations,” Fry says, “In other communities, an opportunity to partner with other providers in a new way by leading may be available.”
The emergency preparedness plan should be updated at least annually because factors affecting the plan often change, Veenema says.
Don’t Forget HIPAA
HIPAA must be factored into emergency plans, Fry notes.
“Hospitals should remember HIPAA continues to apply when crafting their communication plans. Under HIPAA, hospitals can share information with other providers for treatment purposes and the patient’s location, general condition, or death with a patient’s family, but in an emergency, hospitals can also alert aid organizations like the Red Cross to coordinate family notification, and the media in certain circumstances,” he says. “Like always, hospitals should consider what is minimally necessary to accomplish the goal, and if possible, ask the patient before disclosing.”
Blackwood cautions that complying with the CMS CoP requires more than just developing a slick manual of policies and procedures to put on a shelf.
“Providers cannot simply set policies and procedures, a communication plan, and conduct trainings and then forget it,” she says. “Rather, CMS expects an iterative process with annual reviews and updates informed by experiences and training exercises.”
- Hilary S. Blackwood, JD, McGuire Woods, Charlotte, NC. Telephone: (704) 373-8850.Email: email@example.com.
- Timothy J. Fry, JD, McGuire Woods, Chicago. Telephone: (312) 750-8659. Email: firstname.lastname@example.org.
- Tener Goodwin Veenema, PHD, MPH, RN, FAAN, Associate Professor, Johns Hopkins School of Nursing, Baltimore. Telephone: (410) 614-1831.