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Emergency Preparedness Basics: Is Your Program Ready to Go?

The Centers for Medicare & Medicaid Services (CMS) requires that all nursing homes have an emergency preparedness program. With disasters ranging from the COVID-19 pandemic to wildfires and hurricanes seemingly around every corner, taking the following steps can help providers have a program that can stand up to any emergency:

Make sure your program is compliant

“In 2016, CMS issued the emergency preparedness rules of participation (ROPs). Figuratively speaking, these ROPs took emergency preparedness requirements from zero to 60—they are extremely comprehensive,” says Stan Szpytek, an independent fire and life safety/disaster preparedness consultant.

“You need to conduct a hazard vulnerability assessment for your specific facility, and then you must have policies and procedures and an emergency operations plan that address every specific emergency that can occur based on that hazard vulnerability assessment,” he explains. “So the first step is knowing the specific threats and perils your facility faces and making sure that you have a compliant emergency operations plan.”

Appendix Z, “Emergency Preparedness for All Provider and Certified Supplier Types Interpretive Guidance,” in the State Operations Manual delineates the emergency preparedness requirements codified in regulation by the associated E-tag. An emergency preparedness program (E-0001) includes four core elements, each of which have additional substandards designated by additional E-tags:

  • An emergency plan (E-0004) that is based on a risk assessment and that incorporates an all-hazards approach. Note: Find a hazard vulnerability assessment, including the commonly used Kaiser Permanente tool, here.
  • Policies and procedures (E-0013).
  • A communication plan (E-0029).
  • Training and testing (E-0036).

“In March 2019, CMS revised Appendix Z specifically to add infectious diseases as a potential hazard that providers must consider in an all-hazards approach,” says Szpytek. First, CMS updated the definition for an all-hazards approach (changes are italicized):

All-Hazards Approach: An all-hazards approach is an integrated approach to emergency preparedness that focuses on identifying hazards and developing emergency preparedness capacities and capabilities that can address those as well as a wide spectrum of emergencies or disasters. This approach includes preparedness for natural, man-made, and or facility emergencies that may include but is not limited to: care-related emergencies; equipment and power failures; interruptions in communications, including cyber-attacks; loss of a portion or all of a facility; and interruptions in the normal supply of essentials, such as water and food. Planning for using an all-hazards approach should also include emerging infectious disease (EID) threats. Examples of EIDs include Influenza, Ebola, Zika Virus and others. All facilities must develop an all-hazards emergency preparedness program and plan.

In addition, CMS updated the surveyor guidance under E-0004 (changes are italicized):

An emergency plan is one part of a facility’s emergency preparedness program. The plan provides the framework, which includes conducting facility-based and community-based risk assessments that will assist a facility in addressing the needs of their patient populations, along with identifying the continuity of business operations which will provide support during an actual emergency. In addition, the emergency plan supports, guides, and ensures a facility’s ability to collaborate with local emergency preparedness officials. This approach is specific to the location of the facility and considers particular hazards most likely to occur in the surrounding area. These include, but are not limited to:

  • Natural disasters.
  • Man-made disasters.
  • Facility-based disasters that include but are not limited to:

o Care-related emergencies;

o Equipment and utility failures, including but not limited to power, water, gas, etc.;

o Interruptions in communication, including cyber-attacks;

o Loss of all or portion of a facility; and

o Interruptions to the normal supply of essential resources, such as water, food, fuel (heating, cooking, and generators), and in some cases, medications and medical supplies (including medical gases, if applicable).

  • EIDs such as Influenza, Ebola, Zika Virus and others.
  • These EIDs may require modifications to facility protocols to protect the health and safety of patients, such as isolation and personal protective equipment (PPE) measures.

Note: The Office of Inspector General’s Toolkit: Insights for Health Care Facilities From OIG’s Historical Work on Emergency Response can assist providers in implementing these requirements.

Train and exercise staff on the emergency plan

“All staff should be both trained and exercised on the emergency operations plan,” says Szpytek. “It’s relatively easy to do functional exercises and drills that may have a lot of moving parts that occur in a compressed time frame, such as a fire drill or a take-cover exercise for a tornado. It’s more difficult to exercise and plan for a slow-moving emergency, such as a pandemic, a heat wave, or a water shortage due to a drought. You want to specifically focus on those types of emergencies that don’t have multiple moving parts—that involve doing business as usual but with a twist to everything.”

Use ICS culture to know when to activate the plan

“Your emergency plan should be ready for immediate implementation,” says Szpytek. “During the COVID-19 public health emergency, anecdotal reports suggest that many providers didn’t initially react to the pandemic as if it were an actual emergency like an approaching hurricane, a wildfire, or an earthquake. Being ready to pull the trigger early in the incipient stages of an emergency like a pandemic is critical. To do that, the incident command system (ICS) needs to be part of the culture of emergency management that is integrated into your facility. Adopting a constant mindset of incident command can help providers go into the mode of command and control that is needed to react and activate your plan quickly from a facility perspective.”

CMS requires facilities to have an all-hazards plan, which typically is predicated on a system known as the incident command system,” says Szpytek. “The ICS is a standard all-hazards emergency event management system that organizes command and control, operations, planning, and logistics through proper delegation of authority and guides providers through management by objectives. You develop the objectives that need to be satisfied (e.g., evacuation, infection control measures, shelter in place, whatever they might be), and in the incident action planning meeting, the incident command team constantly reviews progress, coming up with new operational periods and new objectives.”

Note: Nursing homes can use a derivative of incident command designed specifically for nursing homes called the Nursing Home Incident Command System (NHICS).

Do post-emergency follow-up

“If you follow the ICS, you should be learning and recording opportunities for improvement throughout an emergency,” says Szpytek. “Upon completion of the emergency (whether it’s a real incident or an exercise), you should do an immediate hot wash and then an after-action report.”

The hot wash is an immediate debriefing after an incident, explains Szpytek. “You should huddle and quickly review what went right and what went wrong while the emergency is still fresh in your staff’s minds.”

The after-action report is a formalized process for reviewing all of the information learned during the emergency and putting them in the context of lessons learned, says Szpytek. “This allows you to properly document and format those lessons learned so that they are available as a learning tool to help you improve your plan and staff training.”

Work collaboratively

In some facilities, the administrator will simply hand off the hazard vulnerability assessment for the maintenance director to complete, notes Szpytek. “That is not how it is supposed to be done. CMS is very specific in the prescriptive guidelines that it should be done collaboratively. The beauty of a collaborative hazard vulnerability assessment is that you get multiple perspectives.”

The same is true with after-action reports, says Szpytek. “For example, the director of nursing services shouldn’t complete an after-action report on their own. Collaboration is essential. Getting together in a meeting where everyone can collaborate and provide different opinions will produce the most beneficial document.”


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