§ 485.920 Condition of participation: Emergency preparedness. The Community Mental Health Center (CMHC) must comply with all applicable Federal, State, and local emergency preparedness requirements. The CMHC must establish and maintain an emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: ( a ) *Emergency plan.* The CMHC must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do all of the following: ( 1 ) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
( 2 ) Include strategies for addressing emergency events identified by the risk assessment.
( 3 ) Address client population, including, but not limited to, the type of services the CMHC has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.
( 4 ) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation.
( b ) *Policies and procedures.* The CMHC must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following: ( 1 ) A system to track the location of on-duty staff and sheltered clients in the CMHC's care during and after an emergency. If on-duty staff and sheltered clients are relocated during the emergency, the CMHC must document the specific name and location of the receiving facility or other location.
( 2 ) Safe evacuation from the CMHC, 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.
( 3 ) A means to shelter in place for clients, staff, and volunteers who remain in the facility.
( 4 ) A system of medical documentation that preserves client information, protects confidentiality of client information, and secures and maintains the availability of records.
( 5 ) The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of state or Federally designated health care professionals to address surge needs during an emergency.
( 6 ) The development of arrangements with other CMHCs or other providers to receive clients in the event of limitations or cessation of operations to maintain the continuity of services to CMHC clients.
( 7 ) The role of the CMHC under a waiver declared by the Secretary of Health and Human Services, 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.
( c ) *Communication plan.* The CMHC must develop and maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and must be reviewed and updated at least every 2 years. The communication plan must include all of the following: ( 1 ) Names and contact information for the following: ( i ) Staff.
( ii ) Entities providing services under arrangement.
( iii ) Clients' physicians.
( iv ) Other CMHCs.
( v ) Volunteers.
( 2 ) Contact information for the following: ( i ) Federal, State, tribal, regional, and local emergency preparedness staff.
( ii ) Other sources of assistance.
( 3 ) Primary and alternate means for communicating with the following: ( i ) CMHC's staff.
( ii ) Federal, State, tribal, regional, and local emergency management agencies.
( 4 ) A method for sharing information and medical documentation for clients under the CMHC's care, as necessary, with other health care providers to maintain the continuity of care.
( 5 ) A means, in the event of an evacuation, to release client information as permitted under 45 CFR 164.510(b)(1)(ii).
( 6 ) A means of providing information about the general condition and location of clients under the facility's care as permitted under 45 CFR 164.510(b)(4).
( 7 ) A means of providing information about the CMHC's needs, and its ability to provide assistance, to the authority having jurisdiction or the Incident Command Center, or designee.
( d ) *Training and testing.* The CMHC must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. If the emergency preparedness policies and procedures are significantly updated, the CMHC must conduct training on the updated policies and procedures. ( 1 ) *Training.* The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.
( 2 ) *Testing.* The CMHC must conduct exercises to test the emergency plan at least annually. The CMHC must: ( i ) Participate in a full-scale exercise that is community-based every 2 years; or ( A ) When a community-based exercise is not accessible, conduct an individual, facility-based every 2 years; or.
( B ) If the CMHC experiences an actual natural or man-made emergency that requires activation of the emergency plan, the CMHC is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the emergency event.
( ii ) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to following: ( A ) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
( B ) A mock disaster drill; or
( C ) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
( iii ) Analyze the CMHC's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the CMHC's emergency plan, as needed.
( e ) *Integrated healthcare systems.* If a CMHC is part of a healthcare system consisting of multiple separately certified healthcare facilities that elects to have a unified and integrated emergency preparedness program, the CMHC may choose to participate in the healthcare system's coordinated emergency preparedness program. If elected, the unified and integrated emergency preparedness program must do all of the following: ( 1 ) Demonstrate that each separately certified facility within the system actively participated in the development of the unified and integrated emergency preparedness program.
( 2 ) Be developed and maintained in a manner that takes into account each separately certified facility's unique circumstances, patient populations, and services offered.
( 3 ) Demonstrate that each separately certified facility is capable of actively using the unified and integrated emergency preparedness program and is in compliance.
( 4 ) Include a unified and integrated emergency plan that meets the requirements of paragraphs (a)(2), (3), and (4) of this section. The unified and integrated emergency plan must also be based on and include all of the following: ( i ) A documented community-based risk assessment, utilizing an all-hazards approach.
( ii ) A documented individual facility-based risk assessment for each separately certified facility within the health system, utilizing an all-hazards approach.
( 5 ) Include integrated policies and procedures that meet the requirements set forth in paragraph (b) of this section, a coordinated communication plan and training and testing programs that meet the requirements of paragraphs (c) and (d) of this section, respectively.
[81 FR 64039, Sept. 16, 2016, as amended at 84 FR 51829, Sept. 30, 2019]