Summary on CMS rule for minimum Emergency …€¦ · Summary on CMS rule for minimum Emergency Preparedness requirements ... and “boots on the ground ... CMS Rule for Minimum Emergency

CMS Rule Summary - 01/2017 5/17/2017

© 2017. Tina T. Wright, MLCHC 1

Summary on CMS rule for minimum

Emergency Preparedness requirements

Tina T. Wright, Program Manager – Emergency Management & Public Information

Southeastern MA Regional CHC Representative

January 2017

Before we begin…

Housekeeping

Please silence your cell phones

Review of evacuation procedures

2

CMS Rule Summary - 01/2017 5/17/2017


Today’s objectives:

Understand the requirements of the new Center

for Medicaid and Medicare Services (CMS) rule

which establishes minimum requirements for

emergency preparedness in healthcare.

Be able evaluate your facility’s ability to meet

these requirements within the timeline

3

CMS rule for minimum EP requirements

REGULATORY REQUIREMENT as a Conditions of Participation (CoP)

Includes 17 provider and supplier types

Must be “in compliance” to participate in Medicare and Medicaid

Four focus areas:

1. Emergency plan

2. Policies and procedures

3. Communications plan

4. Training and testing program (including 2 annual exercises)

All-hazards Risk Assessment tied to each focus area

CMS Rule Summary - 01/2017 5/17/2017


Why this new CMS rule?

“Conditions of Participation (CoPs) and Conditions for Coverage (CfCs) are health and safety regulations which must be met by Medicare and Medicaid-participating providers and suppliers. They serve to protect all individuals receiving services from those organizations”

Creates commonalities between and amongst healthcare facilities

Aligns well with requirements by the Joint Commission, especially for hospitals

Language is heavy with “Coalition” integration

CMS rule, cont.

Providers and Supplies:

Hospitals

Critical Access Hospitals

Long-Term Care

Facilities, Skilled

Nursing Facilities, and

Nursing Facilities

Religious Nonmedical

Health Care Institutions

Ambulatory Surgical

Centers

Hospices

Psychiatric Residential

Treatment Facilities

Programs of All-

Inclusive Care for the

Elderly

Transplant Centers

Intermediate Care

Facilities for Individuals

with Intellectual

Disabilities

Home Health Agencies

Comprehensive

Outpatient

Rehabilitation Facilities

Clinics, Rehabilitation

Agencies, and Public

Health Agencies as

Providers of Outpatient

Physical Therapy and

Speech-Language

Pathology Services

Community Mental

Health Centers

Organ Procurement

Organizations

Rural Health Clinics and

Federally Qualified

Health Centers

End-Stage Renal Disease

Facilities

CMS Rule Summary - 01/2017 5/17/2017


CMS rule, cont.

Timeline

Published to the Federal Registry on Sept. 16, 2016

In effect after 60 days from date of public, Nov. 16, 2016

Have 1 year from effective date to implement, by

Nov. 15, 2017

CMS Rule Summary - 01/2017 5/17/2017


CMS rule, nuances to keep in mind

Risk Assessment

Must be “all-hazards” risk

assessment,

such as a Hazard Vulnerability

Analysis (HVA)

2-fold assessment – facility and

community based

Annual review and maintenance


Emergency Preparedness Plan

Must be based on the results of the Risk Assessment

Address the needs of the your patient populations

Address the types of services the facility can provide in an

emergency

Must include business continuity best practices, such as

delegation of authority and succession plans

CMS Rule Summary - 01/2017 5/17/2017



Policies & Procedures

Based on the risk assessment, EP plan, and communications

plan

Are to include a system for tracking on-duty staff and sheltered

patients during an emergency

Medical documentation sharing if patients transfer to alternate

facility, compliant with federal and state privacy laws

Include policies for Volunteers


Communications Plan

Refers back to EP plan; must comply with Federal and

State laws

Facilitate both internal (staff & patients) and external

(federal, state, local agencies) communications

Must include a “method for sharing information and medical

documentation with other healthcare providers to ensure

continuity of care for patients.”

CMS Rule Summary - 01/2017 5/17/2017



Communications Plan, cont.

Communicate to the local incident command center of an

emergency the facility’s ability to provide assistance

before, during and after the event

Alternate means of communication in case of interruption

in phone service


Training and Testing Program

Review current training programs, compare to risk

assessment, EP plan, communications plan, and policies

and procedures

Provide initial training to all new and existing staff,

individuals providing services under arrangement, and

volunteers, consistent with “expected roles”

Staff must be able to demonstrate knowledge;

documentation of staff training

CMS Rule Summary - 01/2017 5/17/2017



Full-scale Exercise

2 exercises annually, 1 being full-scale while the other is at the facility’s discretion

If full-scale is not an option, a facility-based exercise, as long as it is documented, will meet the requirement

An actual emergency that requires the activation of the emergency plan, as long as it is documented, meets the full-scale exercise requirement for 1 year after the actual event

Analyze response to and maintain documentation of drills, table top exercises, and emergency events

Source: Federal Emergency Management Agency (FEMA)

Emergency Preparedness Exercises: Level of

Complexity

CMS Rule Summary - 01/2017 5/17/2017


Homeland Security Exercise Evaluation

Program (HSEEP) Definitions of Exercises

Discussion-based exercises familiarize participants with current plans, policies, agreements and procedures, or may be used to develop new plans, policies, agreements, and procedures. Types of discussion-based exercises include:

Seminar: A seminar is an informal discussion, designed to orient participants to new or updated plans, policies, or procedures (e.g., a seminar to review a new Evacuation Standard Operating Procedure).

Workshop: A workshop resembles a seminar, but is employed to build specific products, such as a draft plan or policy (e.g., a Training and Exercise Plan Workshop is used to develop a Multi-year Training and Exercise Plan).

Tabletop Exercise (TTX): A tabletop exercise involves key personnel discussing simulated scenarios in an informal setting. TTXs can be used to assess plans, policies, and procedures.

Games: A game is a simulation of operations that often involves two or more teams, usually in a competitive environment, using rules, data, and procedure designed to depict an actual or assumed real-life situation.

Homeland Security Exercise Evaluation

Program (HSEEP) Definitions of Exercises

Operations-based Exercises validate plans, policies, agreements and procedures, clarify roles and responsibilities, and identify resource gaps in an operational environment. Types of operations-based Exercises include:

Drill: A drill is a coordinated, supervised activity usually employed to test a single, specific operation or function within a single entity (e.g., a fire department conducts a decontamination drill).

Functional Exercise (FE): A functional exercise examines and/or validates the coordination, command, and control between various multi-agency coordination centers (e.g., emergency operation center, joint field office, etc.). A functional exercise does not involve any “boots on the ground” (i.e., first responders or emergency officials responding to an incident in real time).

Full-Scale Exercises (FSE): A full-scale exercise is a multi-agency, multi-jurisdictional, multi-discipline exercise involving functional (e.g., joint field office, emergency operation centers, etc.) and “boots on the ground” response (e.g., firefighters decontaminating mock victims).

CMS Rule Summary - 01/2017 5/17/2017



Integrated health system option –

Allows a separate healthcare facility that operates within a

healthcare system to elect to be a part of that system's

unified emergency preparedness program.

Must demonstrate that each separately facility actively

participates

Each facility must demonstrate program implementation and

compliance with requirements at the facility level

CMS rule, cont.

ASPR TRACIE resources:

https://asprtracie.hhs.gov/documents/cms-ep-rule-resources-at-your-fingertips.pdf

CMS Surveyors Interpretive Guidance is due to be published in the Spring 2017 – but DO NOT WAIT

https://asprtracie.hhs.gov/documents/cms-ep-rule-resources-at-your-fingertips.pdf

CMS Rule Summary - 01/2017 5/17/2017


“Failure to meet these minimum

requirements will result in ‘termination’

of participation in CMS programs”As per 10/05/16 call with CMS.

In Dec 2016 at the National Healthcare Coalition

Conference, CMS staff stated that “normal procedures”

for implementing plans to meet compliance would be

acceptable.

Links:

CMS Rule for Minimum Emergency Preparedness Requirements -

https://www.cms.gov/Medicare/Provider-Enrollment-and-

Certification/SurveyCertEmergPrep/Emergency-Prep-Rule.html

10/5 call on the rule recording and slides now available online -

https://www.cms.gov/Outreach-and-

Education/Outreach/NPC/National-Provider-Calls-and-Events-

Items/2016-10-05-Emergency-

Preparedness.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=desc

ending

Assistant Secretary for Preparedness and Response (ASPR)

Technical Resources Assistance Center Information Exchange

(TRACIE) webpage on the rule -

https://asprtracie.hhs.gov/cmsrule

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Emergency-Prep-Rule.html

https://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/2016-10-05-Emergency-Preparedness.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending

https://asprtracie.hhs.gov/cmsrule

CMS Rule Summary - 01/2017 5/17/2017


Thank you!

Questions? Contact Tina Wright, [email protected]

mailto:[email protected]

Documents

Summary on CMS rule for minimum Emergency …€¦ · Summary on CMS rule for minimum Emergency Preparedness requirements ... and “boots on the ground ... CMS Rule for Minimum Emergency