and do the following: identified in risk assessment to be tied to specific risks (3). Address facility population including persons- at-risk, types of service provided in an emergency, continuity of operations, delegation of authority, succession plans New requirement: Resident – specific and service specific risks. Continuity of operations with succession planning Resident –specific risk assessment will be done on your typical population and must address the unique needs they would have in an emergency Business Continuity Plan template (4.) Include process for ensuring cooperation and collaboration with local, tribal, regional, state or fed emergency prep officials to maintain an integrated response during disaster or emergency, including documentation of the LTC facility’s efforts to contact such officials and New requirement: state prep officials – process for ensuring cooperation/collabor ation Integrated response communication channels/contacts for during event participation in planning Develop a method to document the contact and participation with local officials. Could be a letter, a signature on your plan, and agenda and attendance sheet from meetings attended with them Local Healthcare Coalitions are convened in most counties for the purposes of integrated planning. Ask your local or state emergency officials or possibly the health and safety officer of the local hospital how to find out more about the local coalition Need to add a 24/7 contact for emergencies in addition to 911. Also consider alternate method of contact if phones are out
when applicable of its participation in collaborative/coope rative planning (b) Policies and Procedures Based on risk assessment and communication plan (1.) Provision of subsistence needs for staff and residents, whether evac or shelter in place including but not limited to the following is new requirement Taking subsistence along during evac also new No amount of supplies specified by CMS but will be determined by the facility and on their risk assessment. Suggest involve dietary consultant to address amounts, of supplies, storage for Shelter in Place and evacuation at least until residents are in the receiving health care facility. P&Ps must be reviewed and updated at least annually and address the following: i. Food, water, medical and pharmaceutical supplies Pharmaceuticals new Medications - Suggest this be researched with medical director, pharmacies and insurance plans which medications are critical to have, and how to stockpile and/or resupply meds If stockpiled need to develop system for how to and control access. ii. Alternate sources of energy to maintain: A] Temps to protect resident health and safety and safe storage of provisions B] Emergency lighting C] Fire detection, extinguishing, and alarms systems D] Sewage and waste systems New requirement for sewage and waste systems, along with the need to maintain temps for residents and storage of provisions Some facilities may have to replace generators if their risk assessment indicates that a generator is required to meet this need and the addition CMS clarifies – “Alternate sources of energy depend on the resources available to a facility, such as battery-operated lights, propane lights, or heating, in order to meet the needs of a facility during an emergency. We would encourage facilities to confer with local health department and emergency management officials, as well as and healthcare coalitions, to determine the types and duration of energy sources that could be available to assist them in providing care to their patient population during an emergency. As part of the risk assessment planning, facilities should determine the feasibility of relying on these sources and plan accordingly” “…the provision and restoration of sewage and waste disposal systems could be beyond the operational control of some providers.
sources of assistance assistance involves devices and access to the contact info. (4.) Means to shelter in place for residents, staff, volunteers who remain in the LTC Facility Expanded requirement. Staff and volunteers Shelter in Planning Guide (5.) System of medical documentation that preserves, resident’s information, protects confidentiality of resident information, and secures and maintains the availability of records Expanded requirement. Preservation and access of medical documentation not addressed before at state or fed level. EHR – access may be issue Non EHR- preservation may be issue Develop this procedure with facility’s privacy office to ensure that is maintained. CMS has stated this is flexible because of wide range of record keeping systems. This needs to reflect the risk assessment for each facility. If flood or fire are major risks for examples, a plan to relocate all medical records would be expected. (6.) Use of volunteers in an emergency or emergency staffing strategies, including the process and role for integration of state or federally designated health care professionals New requirement Will need to utilize MRCs ESAR-VP Surge strategies for staffing Emergency Staffing strategies EOP template has full section on staffing Surge capacity tools
(d) . Training and Testing program – Develop and maintain an emergency prep training and testing program based on the emergency plan based on risk assessment, P&Ps and communication plan developed and updated at least annually (1.) Training program must do all the following: i. initial training in emergency prep P&P to all new and existing staff, individuals providing services under arrangement, and volunteers consistent with their expected roles Expanded requirement. Volunteers and those under service contracts EOP Template has training section provide at least annually maintain documentation of training demonstrate staff knowledge of emergency procedures (2.) Testing – LTC must conduct exercises to test plan at least annually including unannounced staff drills using the Drill templates
facilitator, 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 LTC facility’s response to and maintain documentation of all drills, table top exercises, and emergency events, and revise the LTC facility’s emergency plan as needed. After Action Template (e) Emergency and standby power systems. (1.) Emergency generator location in accordance found in the Health Care Facilities Code (NFPA 99 and tentative Interim Amendments (TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5 and TIA 12-6), LSC (NFPA 101 and TIA 12-1, 12-2, 12-3, 12- are the same basic requirements for an emergency generator that is installed at a SNF required to provide an alternate source of power for Life Safety Compliance purposes and when life-support equipment is present. So, if it is determined that an emergency Existing requirements
system consisting of multiple separately certified healthcare facilities that elects to have a unified and integrated emergency preparedness program, they may choose to participate in the system’s coordinated EP program. If elected the unified and integrated EP program must do all of the following: development of the unified and integrated EP program Be developed and maintained in a manner that takes in to account each facility’s unique circumstances, patient populations, and services offered. Demonstrate each facility is capable of actively using the unified and integrated EP program and is in compliance with the program. Include a unified and integrated emergency plan that meets preceding requirements and is based on and include: community based risk No “one size fits” or centralized equipment unless fully integrated and able to demonstrate that each facility is actively involved in development and that their unique risks/pt