CMS regulatory requirements and TJC compliance are essential for healthcare organizations to establish robust emergency preparedness programs. These programs help ensure patients', staff, and community safety during emergencies and disasters while maintaining the organizations' eligibility for federal funding and accreditation status. Healthcare providers must continually assess, update, and test their emergency preparedness plans to meet these requirements and standards. Healthcare organizations must meet both CMS and TJC requirements to ensure compliance with federal regulations and maintain accreditation. These requirements are designed to enhance patient safety and the ability of healthcare facilities to respond effectively to emergencies, including natural disasters, infectious disease outbreaks, and other crises. Regular updates and revisions to these requirements may occur, so healthcare providers need to stay informed and adapt their emergency preparedness programs accordingly. Register, https://conferencepanel.com/conference/cms-regulatory-requirements-for-emergency-preparedness-programs-and-tjc-compliance

1. CMS Conditions of Participation
Emergency Preparedness

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Speaker
▪Laura A. Dixon, Esq.
▪ BS, JD, RN, CPHRM
▪ President, Healthcare Risk
Education and Consulting, LLC
▪ 303-955-8104
▪ ldesq@comcast.net
▪ Email questions to CMS:
Critical Access Hospitals: qsog_CAH@cms.hhs.gov.
Acute hospitals: qsog_hospital@cms.hhs.gov.
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3. Introduction
▪ Requirements apply to all participating providers
and suppliers
▪ Ensures such entities plan adequately for natural and
man-made disasters
▪ Plus, coordinate with Federal, state, tribal, regional and
local emergency preparedness systems
▪ Assists providers and suppliers to adequately
prepare to meet need of patients, clients, residents
and participants during a disaster or emergency
situation
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4. Emergency Preparedness Surveys
▪ CoPs will be covered during any type survey
▪ Compliance determined in conjunction with existing Life
Safety Code
▪ May also use survey guidance in appendix Q – Immediate
Jeopardy for Emergency Preparedness
▪ Surveyors to recognize responses to emergencies
may be the same for multiple hazards
▪ Not required to have a P&P for each hazards
▪ Should clearly identify in P&P which circumstances the
facility would evacuate, shelter, etc.
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5. All-Hazards Approach
▪ All-Hazards Approach –
▪ An integrated approach to emergency preparedness
▪ Focuses on identifying hazards
▪ Developing emergency preparedness capacities
▪ Capabilities that can address those as well as a wide
spectrum of emergencies or disasters
▪ Includes:
▪ Natural
▪ Man-made
▪ Facility emergencies
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6. Other Types Emergencies
▪ Care-related
▪ Equipment and power failures
▪ Interruptions in communications – cyber-attacks
▪ Loss of a part/all a facility
▪ Interruptions in normal supply of essentials
▪ Emerging infections disease threats
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7. Emergency Preparedness Program
▪ Facility’s comprehensive approach
▪ To meet the health, safety and security needs
▪ Of the facility, staff, patient population and community
▪ Prior to, during and after an emergency or disaster
▪ Program encompasses four core elements:
– 1. Emergency Plan – based on a Risk Assessment and
incorporates an all-hazards approach
– 2. Policies and Procedures
– 3. Communication Plan
– 4. Training and Testing Program
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8. Mock Disaster Drill
▪ Coordinated, supervised activity
▪ Usually used to validate specific function/capability
▪ In a single agency/organization
▪ Commonly used to provide training on:
▪ New equipment
▪ Validate procedures
▪ Practice and maintain current skills
▪ Determine if plans can be executed as designed
▪ Assess if more training needed or reinforce best practices
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9. Core Elements
of an
Emergency Preparedness Program

10. Training E0036
▪ Must develop and maintain
▪ Emergency preparedness training and testing program
▪ Provide training every 2 years
– After initial training
▪ Based on the Emergency Plan
▪ Based on Risk Assessment
▪ Policies and Procedures
▪ Communication Plan
▪ Must be documented, reviewed and updated at
least every 2 years
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11. Establish Testing Process
▪ Establish a process to include all staff in exercises
over period of time
▪ Consider scheduled exercises with appropriate
department
▪ CMS not requiring use all required equipment in a
drill or percent of patients
▪ Should test according to how would respond in
actual emergency
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12. Emergency and Standby Power
Systems

13. Emergency Generator
▪ Emergency generator inspection and testing –
▪ Must implement inspection, testing and maintenance
requirements per Health Care Facilities Code
▪ If maintain an onsite fuel source to power
emergency generators must
▪ Have a plan for how it will keep emergency power
systems operational during the emergency
▪ Unless facility evacuates
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14. Standards – Emergency Management
▪ Multiple changes for July 2023
▪ Same for Acute and CAH
▪ EM.09.01.01 Hospital has a comprehensive
emergency management program that utilizes an
all-hazards approach
▪ EM.10.01.01: Hospital leadership provides
oversight and support of the emergency
management program
▪ EM.11.01.01: Hospital conducts hazard vulnerability
analysis utilizing an all-hazards approach
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15. Emergency Management Standards
▪ EM.12.01.01: Hospital develops an emergency
operations plan based on an all-hazards approach
▪ Note: Hospital considers its prioritized hazards identified
as part of its hazards vulnerability analysis when
developing an emergency operations plan
▪ EM.12.02.01: Hospital has a communications plan
that addresses how it will initiate and maintain
communications during an emergency
▪ NOTE: Hospital considers its prioritized hazards identified
as part of its hazards vulnerability analysis when
developing an emergency response communication plan
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16. Emergency Management Standards
▪ EM.12.02.03: Hospital has a staffing plan for
managing all staff and volunteers during an
emergency or disaster
▪ NOTE: Hospital considers its prioritized hazards identified
as part of its hazards vulnerability analysis when
developing a staffing plan
▪ EM.12.02.05: Hospital has a plan for providing
patient care and clinical support during an
emergency or disaster
▪ NOTE: Hospital considers its prioritized hazards identified
as part of its hazards vulnerability analysis when
developing a plan for patient care and clinical support
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17. Emergency Management Standards
▪ EM.12.02.07: Hospital has a plan for safety and
security measures to take during an emergency or
disaster incident
▪ NOTE: Hospital considers its prioritized hazards identified
as part of its hazards vulnerability analysis when
developing a plan for safety and security
▪ EM.12.02.09: Hospital has a plan for managing
resources and assets during an emergency or
disaster incident
▪ NOTE: Hospital considers its prioritized hazards identified
as part of its hazards vulnerability analysis when
developing a plan for resources and assets
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18. Emergency Management Standards
▪ EM.12.02.11: Hospital has a plan for managing
essential or critical utilities during an emergency or
disaster incident
▪ NOTE: Hospital considers its prioritized hazards identified
as part of its hazards vulnerability analysis when
developing a plan for utilities management
▪ EM.13.01.01: Hospital has a continuity of
operations plan
▪ NOTE: Hospital considers its prioritized hazards identified
as part of its hazards vulnerability analysis when
developing a continuity of operations plan
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19. Emergency Management Standards
▪ EM.14.01.01: Hospital has a disaster recovery plan
▪ NOTE: Hospital considers its prioritized hazards identified
as part of its hazards vulnerability analysis when
developing a disaster recovery plan
▪ EM.15.01.01: Hospital has an emergency
management education and training program
▪ NOTE: Hospital considers its prioritized hazards identified
as part of its hazards vulnerability analysis when
developing education and training
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20. Emergency Management Standards
▪ EM.16.01.01: Hospital plans and conducts
exercises to test its emergency operations plan
▪ NOTE: Hospital considers its prioritized hazards identified
as part of its hazards vulnerability analysis when
developing emergency exercises
▪ EM.17.01.01: Hospital evaluates its emergency
management program, emergency operations plan
and continuity of operations plans
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21. Items to Consider
▪ Prepare for influx of individuals seeking shelter,
sustenance or care
▪ Consider designated area for “shelter” only
▪ Prepare for at-risk patients
▪ Elderly
▪ Behavioral health/SUD patients
▪ Prepare your staff
▪ For testing or drills
– May trigger an unexpected response
▪ Consider “compassion fatigue” for crisis counselors
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The End Questions???
▪Laura A. Dixon, Esq.
▪ BS, JD, RN, CPHRM
▪ President, Healthcare Risk
Education and Consulting, LLC
▪ 303-955-8104
▪ ldesq@comcast.net
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