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Hospital Accreditation

Emergency Preparedness - Part Two
Posted by
on 1/17/2017 10:00:00 AM
Welcome to the second of a multi-blog series on the new CMS Condition of Participation (COP) for Emergency Preparedness. This new COP took effect in November of 2016. CMS will publish interpretive guidance in the spring of 2017. In this blog, we’ll look at CMS' expectations around the specific policies and procedures that must be included in your hospital's emergency planning efforts.
Required Policies & Procedures
At a minimum, CMS will require that your hospital has policies and procedures addressing the following:
  1. The provision of subsistence needs for staff and patients, whether they evacuate or shelter in place, include, but are not limited to the following:
    • Food, water, medical, and pharmaceutical supplies
    • Alternate sources of energy to maintain the following:
      • Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions
      • Emergency lighting
      • Fire detection, extinguishing, and alarm systems
      • Sewage and waste disposal
  2. A system to track the location of on-duty staff and sheltered patients in the hospital's care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the hospital must document the specific name and location of the receiving facility or other location
  3. Safe evacuation from the hospital, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance
  4. A means to shelter in place for patients, staff, and volunteers who remain in the facility
  5. A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains the availability of records
  6. The use of volunteers in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency
  7. The development of arrangements with other hospitals and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to hospital patients
  8. The role of the hospital under a waiver declared by the Secretary, in accordance with section 1135 of the Social Security Act, in the provision of care and treatment at an alternate care site identified by emergency management officials
In developing and implementing these policies and procedures, there are several important things to keep in mind:
  • As of this writing, CMS has not provided any details as to the minimum scope and content of the policy requirements. We anticipate interpretive guidance to be issued by CMS in the spring of 2017. Any guidance is likely to be specific to policy, with procedure being left to your hospital’s discretion.
  • The policies and procedures should be based on the results of your hospital's emergency preparedness risk assessment (see our first blog in this series), as well as your prioritized emergencies.
  • The policies and procedures need to be developed, implemented, and communicated in a manner consistent with CMS' requirements for an emergency preparedness communication plan (which we will discuss in our next blog).
  • If your hospital has geographically distinct sites of care, has sites of care that serve specialized populations, or has sites of care with a unique or different role in emergency preparedness, then your policies must address these.
  • The policies and procedures can be stand-alone documents or can be included in your hospital’s overall emergency preparedness plan. If they are stand-alone documents, we recommend that a reference table be included in your overall emergency plan so that everyone (including surveyors) will now where they are located and that you have them.
  • The policies and procedures must be reviewed at least annually and any changes or modifications approved at that time. CMS has not prescribed the review and approval process, but we recommend that it include senior leadership and the governing body, as well as your medical executive committee for issues pertaining to your medical staff.
Join me next week as we continue looking at the new COP for Emergency Preparedness
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About the Author

Richard Curtis RN, MS, HACP
RN, MS, HACP

Richard (Rick) Curtis is the Chief Executive Officer for CIHQ. Rick is nationally recognized as an expert on the Medicare Conditions of Participation and the CMS Certification & Survey Process. As CEO, he successfully guided CIHQ in becoming the nation's 4th CMS approved deeming authority for acute care hospitals.
Rick's clinical background is in critical care nursing with a focus in cardiovascular and trauma service lines. He has held both clinical and executive management level positions in Quality, Risk, Education, Infection Control, and Regulatory Compliance.
Rick is a regular speaker at numerous state and national conferences on the federal regulations and accreditation standards, and is host of CIHQ's popular monthly webinars addressing key compliance challenges in today's environment.
Rick is nationally certified in healthcare accreditation, and serves as Chair of the Board of Examiners for the Healthcare Accreditation Certification Program (HACP). Rick has a degree in Nursing with a Master's Degree in Health Services Administration.
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