New Emergency Preparedness Requirements from CMS March 2021

1. HIGHLIGHTS OF CMS UPDATED GUIDANCE FOR EMERGENCY PREPAREDNESS
APPENDIX Z OF SOM, MARCH 26, 2021
QSO-21-15-ALL (CMS.GOV)

2. EMERGENCY PREPAREDNESS PLAN
 Do not think of your facility emergency plan as just something to check-off your list or something the
surveyors make you do.
 Do not just use a template, make sure you tailor it to your facility based on your assessments and exercises.
 Even though this outlines the expectation of the surveyors, this is really about having a plan to keep you, your
staff, and your residents as safe as possible in the event of an emergency.

3. EMERGENCY PLAN DEVELOPMENT
 Plan must describe the patient population of the facility
 Facility must complete an annual all-hazards risk assessment which includes:
 Facility & Community based risk assessment
 Great tool: https://www.calhospitalprepare.org/hazard-vulnerability-analysis
 NFPA risk assessment
 Example: https://www.ihca.com/Files/Comm-Pub/RegBeat/NFPA_99_Facility_Risk_Assessment_Tool.pdf
 Infection control risk assessment (optional)
 Great tools: https://spice.unc.edu/tools-for-success/
 Heat index risk assessment (optional)

4. ELEMENTS OF THE EMERGENCY PLAN
 Natural disasters
 Man-made disasters
 Facility based disasters
 Emerging infectious diseases & Public health emergencies
 Surge planning
 Communication plan
 Continuity of Care (Shelter in place or Evacuate)
 Training and Testing

5. ELEMENTS OF THE EMERGENCY PLAN: NATURAL DISASTERS
 Based on the community based risk assessment and what is prevalent in the facility’s geographical region such
as:
 Tornadoes
 Flooding
 Wildfires
 Extreme heat or cold
 Loss of water / Back up water supply
Should also take into consideration the facility’s patient population and vulnerability
A great resource on natural disaster plans: https://asprtracie.hhs.gov/technical-resources/36/natural-disasters/27

6. ELEMENTS OF THE EMERGENCY PLAN: MAN-MADE DISASTERS
 Instructions for shut-offs and controls (Gas, Electric, Water)
 Heating and Cooling during loss of primary power source
 Must maintain temperature between 71 to 81 degrees
 Fires
 Location and use of alarm systems and signals
 Methods of containing the fire
 Staffing Emergencies
 Staff shortages
 Surge capacity strategy
 Use of volunteers to supplement staffing
 Include non-typical providers and credentialing
 Include what non-licensed/certified volunteer staff can do

7. ELEMENTS OF THE EMERGENCY PLAN: FACILITY BASED DISASTERS
 Care-related emergencies
 Missing residents
 Equipment and utility failures (power, water, gas, etc.…)
 Contracts for essential services should include the re-establishment of essential utility services, the timeframe for the contractor to initiate
services, how they will be procured and delivered, and that the contractor will continue to supply throughout an emergency of varying
duration.
 Also the plan should include a contingency plan such as evacuation if contractor cannot fulfill the need.
 Interruptions in communication, including cyber attacks
 Loss of all or a portion of the facility structure
 Interruptions to the normal supply of essential resources such as food, water, medications, medical supplies (including
medical gases), and fuel (heating, cooking, generators)
 Contracts should include basic inventory and supply needs and surge capacity needs

8. ELEMENTS OF THE EMERGENCY PLAN: EMERGING INFECTIOUS DISEASE
 Covid-19 / SARS-CoV-2
 SARS
 Pandemic Influenza
 Ebola Virus
 Zika Virus
 Bioterrorism
 Potentially infectious Bio-hazardous waste
Must include protecting health and safety of patients, isolation protocols, and personal protective equipment
measures

9. ELEMENTS OF THE EMERGENCY PLAN: PUBLIC HEALTH EMERGENCIES
 This includes: Emerging infectious diseases and Pandemics
 Planning should include a process to evaluate:
 Influx in need of PPE
 Screening of staff, patients, and visitors
 Transfers and discharges
 Home-based healthcare settings/options
 Physical environment changes for social distancing, isolation, surge capacity
 Staffing emergencies
 Process to monitor CDC and other public health agencies event specific guidance for healthcare workers

10. ELEMENTS OF THE EMERGENCY PLAN: SURGE PLANNING
 Contracts for critical care equipment
 Transportation options for surge events
 Surge capacity of facility
 Supplier resources for surge events
 Emergency staffing plan
 Telephonic or Virtual patient visit options

11. ELEMENTS OF THE EMERGENCY PLAN: COMMUNICATION PLAN
 Communication plan that supports coordination of care and interaction with state and local health departments, emergency management agencies,
across healthcare providers, and healthcare coalitions.
 This may include: cell-phone, email, pagers, walkie-talkies, HAM radio, emergency management portals or the use of SHARES:
https://www.cisa.gov/shared-resources-shares-high-frequency-hf-radio-program
 Names and contact information for the following:
 Staff
 Entities providing services under arrangement
 Patients’ physicians
 Evacuation sites
 Volunteers
 Resident contact lists (must be reviewed and updated annually, and document review)
 Federal, state, tribal, regional, and local emergency preparedness staff (FEMA, ASPR, DHS, CMS, etc.…)
 Local emergency management officials (fire, police, etc...)
 State licensing and certification agency
 Office of State Ombudsman
 Public health department
 Other sources of assistance

12. COMMUNICATION PLAN
 The method facility will use to share information and medical documentation with other providers for
continuity of care
 The mean of releasing patient information during an evacuation
 The means of providing information about the general condition and location of patients under the facility’s
care
 Maintain HIPAA compliance
 Must include a means for providing information about facility occupancy, ability to provide assistance to
others, and needs (Staff, Equipment, PPE) to the Incident commander, Emergency operations center, or
jurisdictional authority

13. CONTINUITY OF CARE (THROUGH SHELTER IN PLACE OR EVACUATION)
 Essential personnel
 Essential functions
 Critical resources
 Vital records and IT protection
 Preserves patient information, protects confidentiality, secures availability of records, HIPAA compliant
 Financial resources
 Continuity of care can also describe sheltering off-site and should include transportation, resident identification, and locations of
alternate care sites

14. SHELTER IN PLACE
 How facility will respond to identified patient needs that cannot be addressed in-house during an emergency (just in
time contracts or emergency transfers)
 Services the facility can provide in an emergency under continuity of operations / shelter in place
 The provision of subsistence needs for staff and patients
 Food, Water, Medical, Pharmaceutical supplies
 Alternate sources of energy to maintain safe operations (Typically through a permanent or portable generator – highly suggest quick
connect)
 Temperatures
 Sanitary storage of provisions
 Emergency lighting
 Fire detection, extinguishing, and alarm systems
 Sewage and waste disposal
 Continuity of treatments
 Include generator maintenance and fuel to maintain power

15. EVACUATION
 Written agreements with evacuation sites
 A system for tracking patients and on-duty staff at alternative sites
 Plan must include:
 Consideration of care needs of evacuees
 Staff responsibilities (facility’s role to provide services to evacuees)
 Transportation plan
 Identification of evacuation locations
 Primary and alternate means of communication with external sources of assistance
 How patients will be triaged (and who makes triage decisions)
 What to do if a patient refuses to evacuate

16. EMERGENCY PLAN: TRAINING AND TESTING
 Training must reflect risks identified in the assessment
 Training must include instructions for staff, contractors, agency staff, individuals providing services under
arrangement, and volunteers to ensure aware of emergency preparedness program.
 Training must be documented by certificate or sign-in roster upon hire and annually or with a significant
update to the plan
 Training records should be kept for 2 years

17. EMERGENCY PLAN: TRAINING AND TESTING
Testing: Must do documented 2 exercises annually, records kept for 2-years
1. Annual Full-scale exercise (community based or facility-based functional exercise) unless an actual emergency
activation of plan occurs.
If not conducting community based due to availability, document efforts to identify one to participate in
2. Another annual Full-scale exercise or a mock-drill or a table-top exercise.
Must show documentation of exercise plan, after-action report, and any changes made to plan

18. EMERGENCY PLAN
 Must include delegations of authority and succession plans
 Should outline roles and responsibilities (Incident commander, Public information officer,, Patient/Family liaison, Safety officer)
 Who will coordinate implementation of an 1135 waiver and submit the request to operate under the waiver if federally issued
 Must be shared with residents and their representatives (An informational brochure or a Fact-sheet that
highlights major sections and how information will be communicated such as a web-site or check-ins)

19. EMERGENCY PLAN: OTHER RECOMMENDATIONS NOT IN THE
REGULATION
 Active shooter plan
 Bomb threat response plan
 Laundry back up plan
 A disaster supply checklist
 An emergency menu

20. EMERGENCY PREPAREDNESS PLAN
 Don’t be overwhelmed!
 There are lots of resources out there!

21. DISCLOSURES
 This presentation, created by ARC Talent Design, does not have any commercial support or sponsorship.
 ARC Talent Design has no conflict of interest or vested interest with the educational activities prepared in this
educational material.
 The educational services provided are intended to contribute to the ability of the health care center to
enhance the quality of services provided to the medically underserved population served by the health care
organization.
 The educational activities created by ARC Talent Design do not have any endorsement of any products or
co-providerships.
 This educational presentation is to assist in the understanding of the newly revised regulations, facilities are
advised to also read the CMS memo for more detailed information or to clarify any questions.