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How to Comply with the CMS Conditions
for Coverage on Emergency Preparedness
Bob Loeper, VP Operations Support
Business Continuity/Disaster Response
Fresenius Kidney Care
November 9, 2018
Facilities Impacted by the
Emergency Preparedness Rule
• Hospitals
• Religious Nonmedical Health Care
Institutions (RNHCIs)
• Ambulatory Surgical Centers (ASCs)
• Hospices
• Psychiatric Residential Treatment
Facilities (PRTFs)
• All Inclusive Care for the Elderly
(PACE)
• Transplant Centers
• Long Term Care (LTC) Facilities
• Intermediate Care Facilities for
Individuals with Intellectual
Disabilities (ICF/IID)
• Home Health Agencies (HHAs)
• Comprehensive Outpatient
Rehabilitation Facilities (CORFs)
• Critical Access Hospitals (CAHs)
• Clinics, Rehabilitation Agencies, and
Public Health Agencies as Providers of
Outpatient
• Physical Therapy and Speech
• Language Pathology Services
• Community Mental Health Centers
(CMHCs)
• Organ Procurement Organizations
(OPOs)
• Rural Health Clinics (RHCs) and
Federally Qualified Health Centers
(FQHCs)
• End Stage Renal Disease (ESRD)
Facilities
Developing a Facility Emergency Plan
Hazard Vulnerability
Assessment (HVA)
• Define Hazards expected in your community
• Rank hazards by probability, risks and
preparedness
• Define Mitigation Strategies for top 5 to 10
hazards
• Show proof of mitigation strategies
• IDT must participate in completing the HVA,
including the Medical Director
Hazardous Vulnerability Analysis
Type of Disasters
• Hurricane• Tornado• Wild Fires• Earthquake• Winter Weather• Flood• Drought• Chemical Spill• Water Main
Break
• Power Outage• Equipment Failure (RO)• Pandemic• Civil Unrest / Riots• Volcano• Nuclear Incident• Ransomware
Hazardous Vulnerability
Analysis
Hazardous Vulnerability Analysis
(HVA)
Type of Disaster Probability of
Occurring?
Impact on Persons,
Property or
Business
Preparedness level or
Internal & External
Resources
Total
3 - High 3 - High 0 - Very Good
2 - Medium 2 - Medium 1 - Good
1 - Low 1 - Low 2 - Fair
0 - None 0 - None 3 - Poor
HAZARD VULNERABILITY ASSESSMENT TOOL
SEVERITY
EVENTPROBABILITY RISK PREPARED-NESS Total
Likelihood this will occur
Possibility of death or injury / Physical
Damage / Dialysis Interruption
Preplanning
Those events with a higher score should be prioritized; as these events
will require additional planning and preparation.
SCORE
0 = N/A 1 = Low 2 = Moderate 3 = High
0 = N/A 1 = Low 2 = Moderate 3 = High
3 = Low / None 2 = Moderate 1 = High 0 = N/A
0 - 9
Volcano 0 0 0 0Hurricane 0 0 0 0Tornado 0 0 0 0
Fire 0 0 0 0Ice Storm 0 0 0 0
Earthquake 0 0 0 0Floods 0 0 0 0Blizzard 0 0 0 0
Electrical Failure 0 0 0 0Water Interruption 0 0 0 0
Drought 0 0 0 0Hazardous Material Spill 0 0 0 0
Terrorism Act 0 0 0 0Bomb Threat 0 0 0 0
Active Shooter 0 0 0 0Nuclear Plant Accident 0 0 0 0
Civil Disturbance 0 0 0 0Pandemic 0 0 0 0
Cyberterrorism / Ransomware 0 0 0 0
Other Local Event 0 0 0 0
Facility Name: Facility #:Preparer: Date:
Only values of 0, 1, 2 or 3 will be accepted for Probability, Risk and Preparedness.
• Procedures to determine the need to evacuate prior
to a hurricane have been established.
• A Memorandum of Understanding with an
engineering firm to complete a Building Damage
Assessment is in place. Ensure you have contact
information for the engineering firm.
• Plastic sheeting and duct tape are on hand to cover
up equipment and windows if necessary.
Hurricane Mitigation StrategiesType of Disasters
• Portable pumps and sandbags are available
• Secure all items susceptible to blowing away, bring these items inside if possible.
• Store and secure all critical records at least 2’ above the floor in the event flooding occurs.
• Fill up the fuel tanks in vehicles and generators prior to landfall.
• Hotel accommodations are available to house staff if necessary.
• Frozen cool packs are available to place in medication refrigerators if needed.
Hurricane Mitigation StrategiesType of Disasters
• Medical equipment, dialysis machines and computers are
secure, elevated and covered in plastic.
• Regulated medical waste is collected, secured and stored in
locked Medical Waste room
• Weather Radio with a warning alarm tone and battery backup
is available.
• Facility shutdown procedures are in place.
• Warning and evacuation plans and procedures are in place.
• Transportation assistance is available if needed.
• Hurricane shutters are in place or 5/8” marine plywood is on
hand to protect windows.
Hurricane Mitigation Strategies
Components of the Facility Emergency Plan
Emergency Operations Center
• Contact your local EoC and discuss your capabilities during a
disaster and understand their role in emergency preparedness
and response
• Seek and join local healthcare coalitions
• Surveyors will ask: Which Coalition do you belong to?
• Determine location of medical/special needs shelters;
• Determine if patient registration is required;
• Determine re-entry requirements post mandatory
evacuation;
• Participate in community drills
Components of the Facility
Emergency Plan• Create a facility manual to provide an overview of the facility emergency plan
and depository for all documents
• Define roles and responsibilities for each staff member:
• Facility Administrator as Incident Commander; complete authority over the
event, authorizes resources, declares the disaster and when event is over
• Social Worker: Contact missing patients and arrange transportation
• Administrative Assistant: Coordinate staffing needs and transfer/admit patients
• Registered Dietitian: Coordination with local hospital and other external
agencies
• Direct Patient Care staff: RNs and PCTs to assist with patient emergency
education, participate in facility evacuation drills, assisting patients
• Medical Director and attending physicians : help in locating your patients after
a disaster, provide orders for patients who present to clinic with no medical
records
Components of the Facility
Emergency Plan
• Create Facility Emergency Contact Information Form
• Hierarchal contact information; Admin/Area/Regional,
Med Dir
• Facility: Landlord, Electrician, Plumber, HVAC, Fuel
• Community: Police, Fire, Telephone, Water, Power
• Regulatory: FEMA, EOC, Network, Red Cross, NKF,
National Guard
• Emergency Housing: Hotels, Campgrounds
• Back up Facilities
• Volunteer groups or local agencies that may provide
assistance
Components of the Facility
Emergency Plan
• Create Staff Emergency Contact Information
Form
• List all staff contact information including cell and emails
• Know staff driving distance form facility
• Include secondary contact information
• Pull electronically from exiting data fields
• Print quarterly for review and compliance
‘If we don’t take care of our staff,
we can’t take care of our patients’
Tracking Patient Emergency
Contact Information
• Create Patient Emergency Contact Information Form and
update at least quarterly
• Know how to get in touch with your patients, include
family members and alternate contact information
• Know their expected evacuation plan
• Identify who will go to special needs shelter during
evacuation
• Register for shelter if required
• Review/update with patients prior to event if possible
• All patients must be accounted for during a disaster
Homeland Security Re-Entry Authorization
Know what your EoC Requires
Facility Authorization Letter
To Whom It May Concern:
The individual carrying this letter is authorized by the National Incident Commander for
Fresenius Medical Care North America to respond to the medical and infrastructure needs
of patients who require life sustaining medical treatment in a Fresenius Medical Care
facility. As such, this individual should be allowed to travel freely and without interruption
or interdiction to and from whatever location that requires his/her assistance.
If you require any further authorization or information, please contact me immediately at
813-843-4423.
Robert P Loeper
National Incident Commander
Fresenius Medical Services
Disaster Response Team
Vice President of FMS Strategic Project Management
Facility Emergency
Supplies and Equipment
• Does facility have a back up analog phone and line
available?
• Emergency equipment to include AED (checked daily), O2
tanks, suction, Ambu bag, IV solutions, back board, oral
airways
• Are emergency medications checked monthly or after use
for expiration dates, cleanliness and proper function
Agreements to include in your Facility
Emergency Plan• Facility Back up Agreement, with multiple facilities
• Alternate water source agreement
• Alternate power source/emergency generator agreement
• HVAC maintenance and repair agreement
• Emergency response agreements with electricians, plumbers,
contractors
• Emergency transportation agreements
• Rental car/van/truck agreements
• Security services agreements
• Environmental testing agreements, Arcadis
• Physical Pant Mitigation Agreements; ServPro, ACT, Service Master
• Debris removal services
Develop Facility Policy and Procedures
to follow Emergency Plan
• Gap Analysis to review current Policies versus CfC:
• Policies and procedures must include emergencies regarding fire
equipment, power failures, care related emergencies, water supply
interruption & natural disasters (existing requirement).
• Tracking during and after the emergency applies to on-duty staff and
sheltered patients.
• Facility Emergency Preparedness Policy/Operations Manuals
• Facility Physical Plant Preparation Assessment and Return to
Operations
Patient Training and Communication Plan
• Quarterly incenter fire drills / facility evacuation
• Emergency disconnect, hand crank blood pump, document patient
verbally understands the process demonstration verbally;
• Dialysis facility staff should show patients what to do if on a dialysis
machine in an emergency. The instructions should include where an
emergency pack is kept and how to disconnect themselves from the
dialysis machine.
• Facility evacuation, know which doorways to exit if patient in chair
Disaster Response• Provide patient with their copy of the
printed information (Care Transition
Report). Keep one copy at the facility
for reference as needed.
• Verify emergency contact information
for patient and location.
• Provide patients with facility phone
number and other emergency
contact information.
Care Transition Report• Treatment orders
• Dietary orders
• Current in-center and home
medications
• Latest laboratory results
• Trends in vital signs
• Hepatitis status
• Allergies
• Active co-morbids
• Demographic Information Sheet
• EPO conversion charts
Disaster Response
Training and Testing requirements due
Annually
• Completed at least one tabletop exercise annually with IDT
• Seek out and to participate in a full-scale, community-based
exercise annually with your local and/or state emergency
agencies and health care coalitions, or if not available in your
community:
• Complete an individual facility-based exercise and document the
circumstances as to why a full -scale, community-based exercise was
not completed
• Document what emergency agencies and/or health care coalitions
you contacted to partner in a full-scale community exercise and the
specific reason(s) why a full-scale exercise was not possible.
Actual Disaster or Emergency
• If your facility was involved in a actual disaster or emergency
where your facility emergency plan was activated where you
interacted with other providers and agencies in the
community you must:
• Complete the After Action Review
• Include pictures, news articles
• Present in QAI
• Facility is exempt from Community Wide drill for 12 months
After Action Report/Improvement Plan
• Brief overview of the exercise
• Major strengths demonstrated during the exercise
• Areas that require improvement
• Complete the After Action Review
Report/Improvement Plan (AAR/IP) to document.
• File the completed AAR/IP in the designated
Disaster/Emergency Response binder.
• Report exercise and outcome in QAI.
Training and Testing Requirements
Due Annually
• Documentation that all staff completed annual emergency
training
• Documentation that all patients completed annual
emergency training
• Documentation that all facility credentialed providers
completed annual emergency training
• Medical Director, Attending Physicians and Extenders ( PAs,
ARNPs)
Patient Emergency Plan
• WHO will I keep in touch with if there is an
emergency?
• WHAT will I pack in my emergency kit?
• WHERE will I go if I need to evacuate my home?
• WHEN will I share my plan with others?
• HOW will I get treatment in a disaster or emergency?
Emergency Medication/Medical Supply List
• First aid kit
• 5-7 day supply of all your medicine(s)
• 5-day supply of antibiotics (if you use peritoneal dialysis
and recommended by your doctor)
• Diuretics (fluid pills), sorbitol, and Kayexalate for potassium
control (if recommended by your doctor)
If diabetes or heart disease keep 5-7 days of all blood
pressure, diabetes, heart, or anticlotting medications.
Medication/Medical Supply List
Kidney Center Emergency Response
(KCER)
The Kidney Community Emergency Response (KCER) Program provides technical
assistance to End Stage Renal Disease (ESRD) Networks, kidney organizations, and
other groups to ensure timely and efficient disaster preparedness, response, and
recovery for the kidney community.
Mission
Collaboratively develop, disseminate, implement, and maintain a coordinated
preparedness and response framework for the kidney community.
Vision
KCER serves as the leading authority on emergency preparedness and response for
the kidney community by providing organization and guidance that seamlessly bridges
the needs of emergency management stakeholders and the ESRD community
nationwide.
www.kcercoalition.com/
Chronic Ambulatory Peritoneal Dialysis
• Patients who use an ultraviolet device should
be advised to keep the battery charged at all
times. The fully charged battery pack should
last for 3 days.
• Patients should keep a 5-7 day supply of
peritoneal dialysis supplies at home. Check
expiration dates and replace as needed or
every 6 months.
Continuous Cyclic Peritoneal Dialysis
• Patients who use a cycler, may want to
purchase a gasoline powered generator that
makes 110 volt AC alternating current.
Patients who have a car can run their cycler
off the cigarette lighter by using a 12 volt DC
to a 110 volt AC invertor (available at
electronics stores). If the car is in a garage,
make sure there is plenty of fresh air and
good ventilation.
• CCPD patients should learn manual CAPD. In
the event of a power loss and don’t have a
generator, switch from CCPD to manual
CAPD.
• If prolong period of no power, facilities can
allow the patient to bring their cycler into
the facility 3 times a week
CAPD and CCPD
Patient Emergency Plans
PD or Home Hemodialysis
• Contact your water and power company ahead of time to
register for special priority to restore your lost services.
• Keep their phone numbers up-to-date and easy to find.
• Keep a flashlight and batteries near your dialysis machine.
• Prepare an Emergency Stock of Supplies,
Medicines/Medical Supplies, and Food
• Keep a 5-7 day supply of peritoneal dialysis supplies and
medications at home.
• Check expiration dates and replace as needed or every 6 months.
Water
• Keep distilled or bottled water on hand for
drinking. If the patient runs out of stored
water, they may disinfect available water for
drinking, brushing their teeth, or for other
uses.
Do not use disinfected water for dialysis
Overall Best Practices
• Post Back Up clinic location when closing a clinic
• Hand out medical records to all patients prior to
closing
• Display the 3 day renal diet during Lobby Day
• Have copies of all staff and patients emergency
contact info in emergency evacuation box
• Contact electrical/plumber vendors (2 deep) day
before closing to ensure availability
• Coordinate closures among facilities along storm
path
Overall Best Practices
• Standardize reporting times and content of clinic closure reports
• Properly prepare clinic for closure
• RMW off the floor and out of shed, locked in RMW room if not picked up
• All records/document off low level shelves/drawers, sealed in water tight containers
• Machines doubled bagged top down, bottom up
• Equipment away from windows
• Secure all outside fixtures, outbuildings
Overall Best Practices
• Opening a clinic after storm, use buddy system
• Walk the exterior first, check for building cracks; sink holes
• One person remain outside while inside is inspected
• Open close windows/doors, check of jams, floor cracks
• Report any damage to leadership and claims adjuster
• Develop of Incident Command teams ready to deploy
• Standardize roles and responsibilities of the team leads
Surveyor E Tag Worksheet
Surveyor E Tag Worksheet
Surveyor E Tag Worksheet
Surveyor E Tag Worksheet
E Tags and P&PsETAGS Emergency Preparedness for ESRD Policy and Procedure Reference Policy Hyperlink
E-0001
Written Emergency Preparedness (EP) program
• Interview the facility leadership and ask him/her/them to
describe the facility’s emergency preparedness program.
• Ask to see the facility’s written policy and documentation on
the emergency preparedness program.
FMS-CS-IC-II-130-014A Guidelines for
Emergency Preparedness Policy
E-0003
Dialysis facility complies with all federal, state and local EP
requirements.
The emergency preparedness program must describe a
facility's comprehensive approach to meeting the health and
safety needs of their patient population during an emergency;
as well as the whole community during and surrounding an
emergency event (natural or man-made).
• Ask to see written or electronic documentation of the
program.
FMS-CS-IC-II-130-014A Guidelines for
Emergency Preparedness Policy
E-0004
Emergency plan developed and updated annually
• See a copy of facility emergency plan and review for
required elements
• Verify documentation that plan has been reviewed and
updated annually by looking for documentation of the date of
the review and updates that were made to the plan based on
the review
FMS-CS-IC-II-130-014D3 Emergency and
Disaster Staff Contact Information Sheet
FMS-CS-IC-II-130-014D4 FKC Emergency
Disaster Patient Contact Information Sheet
FMS-CS-IC-II-130-014D5 FKC Facility Emergency
Information Directory
E-0006
Document a risk assessment using an all-hazards approach
• Hazards common to the state you are in (natural, man-
made, facility, infectious disease, etc.)
• Ask to see documentation of facility risk assessment and
associated strategies.
• Interview the facility leadership and ask which hazards (e.g.
natural, man-made, facility, geographic) were included in the
facility’s risk assessment, why they were included and how the
risk assessment was conducted.
• Verify the risk-assessment is based on an all-hazards
approach specific to the geographic location of the facility and
encompasses potential hazards.
FMS-CS-IC-II-130-014A Guidelines for
Emergency Preparedness Policy
QIP Exemptions
• CMS does have a rule which can be used to apply for a facility
exemption from Quality Incentive Program (QIP) calculations during
emergency/disaster conditions. More information regarding the
completion of exemption requests for QIP calculations during an
emergency/disaster can be found at this link:
• For emergency closures during 2016 and beyond, facilities can request an
Emergency Exemption Form (ECE) from [email protected] via email,
and file it through http://www.qualitynet.org , within 90 days after the end of
the emergency event.
• Upon review of application and the supporting documents, CMS can exempt
a facility from QIP scoring for the affected month(s) without impact on the
QIP Total Performance Score.
Clinics do not have to be closed to apply f
or the QIP Exemption.
Want To Learn More
Directly From CMS?
CMS is offering an additional learning session through the
Medicare Learning Network regarding the final rule for
Emergency Preparedness Requirements
Thursday, April 27, 2017
from 2:30 PM to 3:30 PM
To register or for more information visit:
MLN Connects Event Registration