Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

CMS Preparedness Gap Analysis

Sample gap analysis for institutional implementation of the CMS Preparedness Rule

  • Be the first to comment

  • Be the first to like this

CMS Preparedness Gap Analysis

  1. 1. Emergency Management Gap Analysis for 2016 CMS Preparedness Rule for Units, Departments, and Off-Site Locations of the (Facility) Final Version, Page 1 of 4 Element CMS TJC Modification Type Action Required How to Accomplish Organization 42 CFR Part 482.920 (c) (7) 42 CFR Part 418.113 (c) (7) EM.02.02.01 EP8 Standardize Development of a standard reporting structure for unit/department integration into the (FACILITY) Incident Command System for offsite locations Develop one-pager to accompany unit/department Disaster Binders Plans 42 CFR Part 482.15 (f) (4) (ii), et. al. EM.01.01.01 EP2, EP4 EM.03.01.01 EP1 Standardize Hazard Vulnerability Analysis to be conducted and documented for each separately certified facility within the health system, utilizing an all-hazards approach Add/revert back to individual Hazard Vulnerability Analysis in the Disaster Binder 42 CFR Part 482.15 (a) (2), et. al. EM.01.01.01 EP5 Standardize Implement the addition of the Mitigation Action Strategy (MAS) template to accompany each facility Hazard Vulnerability Analysis Add the Mitigation Action Strategy document to the unit/department Disaster Binder 42 CFR Part 482.15 (a) (1), et. al. Add Include the community-based risk assessment (THIRA, HVA, etc.) in documentation Add the community- based risk assessment to the Emergency Operations Plan 42 CFR Part 482.15 (b) (1) (ii) (c), et.al. Add Adopt fire plan into Emergency Operations Plan Add Fire Plan as an annex to the Emergency Operations Plan – for offsite locations, include use of alarms and methods of containing fire in Disaster Binder 42 CFR Part 482.15 (c), et. al. EM.02.02.01 EP2 Standardize Consolidation of all contact information for staff, vendors/contractors, medical staff, other hospitals, volunteers, regional Develop a standard method and product for maintaining contact
  2. 2. Emergency Management Gap Analysis for 2016 CMS Preparedness Rule for Units, Departments, and Off-Site Locations of the (Facility) Final Version, Page 2 of 4 Element CMS TJC Modification Type Action Required How to Accomplish response entities, local public safety officials information for all listed individuals and entities 42 CFR Part 482.15 (c) (4) (5) (6), et. al. EM.02.02.01 EP12 Enhance Strengthen clarity of, circumstances surrounding, and process for protected information sharing practices in disasters (i.e. evacuation) Build into of the (FACILITY) Emergency Operations Plan 42 CFR Part 485.920 (c) (7) 42 CFR Part 418.113 (c) (7) EM.02.02.01 EP8 Add All units/departments of (FACILITY) and offsite locations must be able to report status to the (FACILITY) Command Center Review and modify Disaster eWorksheet to ensure all locations are included – provide training/tip sheets as necessary 42 CFR Part 482.15 (b) (1), et. al. EM.02.02.09 EP2 Add Inclusion of specific energy plans to maintain temperature of care environment and provisions, emergency lighting, fire detection/extinguishing/alarm systems, and sewage and waste disposal Add to of the (FACILITY) Emergency Operations Plan 42 CFR Part 482.15 (b) (2), et. al. EM.02.02.07 Add Inclusion of an on-duty staff and patient accountability and tracking system Add to §C.10 of the (FACILITY) Emergency Operations Plan and include the tracking mechanism in the unit/department disaster binder for all locations ((FACILITY) and offsite) 42 CFR Part 482.15 (b) (3), et. al. EM.02.01.01 EP2 Enhance Evacuation plans to include consideration of care and treatment needs of evacuees, staff responsibilities, transportation, identification of Overhaul the (FACILITY) Evacuation Policy
  3. 3. Emergency Management Gap Analysis for 2016 CMS Preparedness Rule for Units, Departments, and Off-Site Locations of the (Facility) Final Version, Page 3 of 4 Element CMS TJC Modification Type Action Required How to Accomplish evacuation location(s), and primary/alternate means of communicating with external sources of assistance 42 CFR Part 482.15 (b) (4), et. al. EM.02.01.01 EP2 Evacuation plans to include provisions for sheltering-in-place for patients, staff, and volunteers who remain at a facility 42 CFR Part 482.15 (b) (5), et. al. EM.02.02.11 EP8 Add Inclusion of a system of medical documentation that preserves patient information, protects confidentiality, and secures and maintains availability of records Adopt the (FACILITY) Downtime Policy as an Annex to the (FACILITY) Emergency Operations Plan 42 CFR Part 482.15 (b) (6), et. al. EM.02.02.13 EP1 Enhance Inclusion of a process for rapid registration, credentialing (when appropriate), and integration of health care professionals into a response Add to of the (FACILITY) Emergency Operations Plan 42 CFR Part 482.15 (b) (7), et. al. EM.02.02.11 EP3 Add Formalize the arrangements/process for other facilities to receive patients in the event of limitations or cessation of operations to maintain the continuity of services (specifically, hospice, mental health, and dialysis) Add to of the (FACILITY) Emergency Operations Plan 42 CFR Part 482.15 (b) (8), et. al. Add Develop the role of the organization to operate under an 1135 waiver issued by the Secretary of Health and Human Services Add to the (FACILITY) Emergency Operations Plan Training 42 CFR Part 482.15 (d) (1) (i), et. al. Enhance Initial training for all new and existing staff, contractors, and volunteers consistent with their role in a disaster Develop a curriculum, formalize in policy by adding to the (FACILITY) Comprehensive42 CFR Part EM.02.02.07 Enhance Provide emergency preparedness
  4. 4. Emergency Management Gap Analysis for 2016 CMS Preparedness Rule for Units, Departments, and Off-Site Locations of the (Facility) Final Version, Page 4 of 4 Element CMS TJC Modification Type Action Required How to Accomplish 482.15 (d) (1) (ii), et. al. EP7 training at least annually to all staff Emergency Management Program policy 42 CFR Part 482.15 (d) (1) (iv), et. al. Enhance Ensure staff have the opportunity to demonstrate staff knowledge of emergency procedures and document accordingly Exercises 42 CFR Part 485.920 (d) (2) 42 CFR Part 418.113 (d) (2) EM.03.01.03 Add Ensure the hospital inclusive of in- patient hospice and out-patient behavioral health participates in exercises Provide specific instruction to these services (contracted or otherwise) during exercise development, execution, and after- action reporting. Note: Of the 17 providers identified in the CMS Rule, the (facility) will assume responsibilities for the following CMS-designated facility’s preparedness operation. It is acknowledged that two (*) of these services are provided on the hospital campus and therefore will meet many of their individual requirements through participation in the hospital’s emergency management program:  Hospitals (42 CFR Part 482.15)*  Hospice (42 CFR Part 418.113)*  Outpatient Behavioral Health – Community Mental Health Centers (42 CFR Part 485.920)

×