When disaster strikes, it is imperative for healthcare organizations to have an efficient emergency preparedness plan in place. The COVID-19 pandemic that has resulted in a global Public Health Emergency (PHE) has reinforced the importance of being prepared for all-hazards that can impact care delivery, including infectious diseases. Many healthcare organizations are already dealing with the impacts of the coronavirus pandemic – patients and their caregivers are refusing to receive in-home care, skilled nursing facilities need to overhaul their operations, and home health agencies are faced with clinical challenges from the pandemic and the new reimbursement model PDGM. These impacts have caused organizations to swiftly adapt and find solutions that keep their patients and staff safe, as well as try to keep operations on track during a time of confusion and stress. Taking steps to develop and instill a well-thought-out, compliant emergency preparedness plan for guidance when immediate action is necessary will help to quickly address any adverse impacts and make adaptability to rapid change much easier.

CMS Emergency Preparedness Regulations in Healthcare

On September 8, 2016, CMS published the Emergency Preparedness Requirement Final Rule in the Federal Register. The purpose of this final rule was to create a framework around national emergency preparedness to ensure healthcare organizations are prepared for all types of disasters, whether man-made or naturally occurring. These emergency plans needed to be compliant with CMS regulations for organizations to qualify for participation in the Medicare or Medicaid program. The rule was published with a provision that all healthcare organizations were to be compliant by November 15, 2017. Healthcare organizations had to outline three major pillars of their emergency preparedness plan to achieve compliance: patient safety, employee safety, and operational response and mitigation.

The Emergency Preparedness Final Rule was updated by CMS in 2019 to include an all-hazards approach to infectious diseases (EIDs). There is now more emphasis on conducting regular Hazard Vulnerability Assessments as the severity of impact of the pandemic and other events is realized. Organizations must be prepared to complete frequent self-assessments, ensuring safety is at the forefront of operations. Because of the severity of the COVID-19 pandemic, we can also expect to see COVID-19’s impacts considered in the all-hazard risk assessment for 2020 and 2021.

Creating an Effective Emergency Preparedness Plan

As emergency preparedness requirements continue to grow and develop with the ever-changing landscape of the healthcare industry, keeping up with these changes and ensuring all departments of an organization are compliant is no simple task. It is of paramount importance to have an active and dedicated emergency preparedness committee.

A quality, compliant emergency preparedness plan must be implemented quickly in extremely stressful conditions, be understood by all parties, and most importantly – it must be effective. There are many elements to consider when creating an emergency preparedness plan. Below are suggestions of what your emergency preparedness committee should consider:

• Knowledge of Federal, State, local and tribal regulations
• Strategies for addressing events identified by the risk assessment in organization’s region or regions
• Directing staff during a crisis
• Providing uninterrupted care for the patients (even in the event of a loss of power or evacuation)
• Maintaining supplies, DME and medication availability for patients
• Notification process for emergency personnel to identify high risk level patients
• Identifying critical access hospitals and other shelters
• EMR preparedness and alternative documentation methods
• Data backup and recovery planning
• Media, financial, insurance and legal management
• Post emergency mitigation and recovery
• Replenishing of supplies or equipment utilized during emergency
• Communication methods before, during and after an emergency while protecting patient privacy
• Preparing staff with drills
• Determination of 1135 waiver authority and process
• Continuity of Operations Planning (COOP) with contracted healthcare organizations
• Implementation of COVID-19 response regulations

An organization’s emergency preparedness plan should be a living document to easily accommodate any changes that need to be made quickly. Scope and severity of the emergency event will determine reaction and activation of the emergency plan by leadership. Preparing your team for this process will save valuable time and reduce confusion in a time of potential stress.

Taking the necessary steps to create an emergency preparedness plan before the emergency occurs will help protect your organization, your patients and your staff. If your organization is in need of support with developing or revising their emergency preparedness plan, consider a third-party organization that can assist with reviewing or updating your emergency plan to ensure compliance with CMS guidelines. Contact McBee for a remote evaluation of your plan’s efficiency that can help you identify if your organization is at risk.