Home Health – New Conditions of Participation – Emergency Preparedness

Preparing for an emergency is key in today’s turbulent world.  Home health agencies, just like any other business, need to be ready if a crisis occurs.  The new Conditions of Participation (CoPs) covers emergency preparedness in Standard 484.102.  The new CoPs will be effective Jan 13, 2018.

However, the new Organizational Environment Condition of Participation for Emergency preparedness implementation date is November 15, 2017, and this standard applies to home health and hospice, along with 17 other different provider types.  There are 44 new E tags for implementation of the new emergency preparedness requirement for the 17 providers and supplier types eligible for participating in the Medicare Program including home health agencies.  Twenty-one of the 44 new E tags apply to home health agencies

All training and testing requirements must be completed by November 15, 2017. Compliance to the Emergency Preparedness Condition requirements will be surveyed as of November 15, 2017.  Home health agencies must prepare in advance in order to ensure compliance to the 21 E tags by the due date of November 15, 2017.  This date, of course, precedes the CoPs effective date of Jan 13, 2018.

In the new home health CoPs emergency preparedness condition, there are four standards:  emergency plan, policies and procedures, communication plan, and training and testing program.  We will explain each standard in detail below.

Emergency Plan

Every home health agency (HHA) must develop and maintain an emergency plan that is reviewed and updated at least annually.  This plan must be comprehensive and include many different areas.  First, it must be based on and include a documented, facility-based and community based risk assessment, utilizing an all-hazards approach.  Cybersecurity is included in the latest list of hazards.  Second, it must include strategies for addressing emergency events identified by the risk assessment.  Next, it must address patient population, including, but not limited to, the type of services the HHA has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.  Finally, it must include cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or an emergency situation.  This includes documentation of the HHA’s efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts.

Policies and Procedures

The HHA must develop and implement emergency preparedness policies and procedures based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section.  This also must be reviewed and updated at least annually.

At a minimum, the policies and procedures must address the plans for the HHA’s patients during a natural or man-made disaster.  Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at § 484.55.  The procedures must include informing State and local emergency preparedness officials about HHA patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment.  Also, included are the procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency.  The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact.  The policies and procedures must include a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains the availability of records.  Finally, it should cover the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State or Federally designated health care professionals to address surge needs during an emergency.

Communication Plan

The HHA must develop and maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and must be reviewed and updated at least annually.

The communication plan must include names and contact information for the following:

(i) Staff

(ii) Entities providing services under arrangement

(iii) Patients’ physicians

(iv) Volunteers

Contact information for the following:

(i) Federal, State, tribal, regional, or local emergency preparedness staff

(ii) Other sources of assistance

The communication plan must also include primary and alternate means for communicating with the HHA’s staff, Federal, State, tribal, regional, and local emergency management agencies.  Along with this information there must be a method for sharing information and medical documentation for patients under the HHA’s care, as necessary, with other health care providers to maintain the continuity of care.  It must also be a means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4).  Finally, it has to be a means of providing information about the HHA’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

Training and Testing Program

The HHA must develop and maintain an emergency preparedness training and testing program that is based on the emergency, risk assessment, policies and procedures, and the communication plan.  The training and testing program must be reviewed and updated at least annually.

For the training program, the HHA must do all of the following:

(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.

(ii) Provide emergency preparedness training at least annually.

(iii) Maintain documentation of the training.

(ii) Demonstrate staff knowledge of emergency procedures.

For testing the HHA must conduct exercises to test the emergency plan at least annually.  The HHA must do the following:

(i) Participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based.

(ii) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in a community-based or individual, facility-based full-scale exercise for one year following the onset of the actual event.

Conduct an additional exercise that may include, but is not limited to the following:

(A)  A second full-scale exercise that is community-based or individual, facility based.

(B)  A tabletop exercise that includes a group discussion led by a 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.

Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed.

If a HHA is part of a healthcare system consisting of multiple separately certified healthcare facilities that elects to have a unified and integrated emergency preparedness program, the HHA may choose to participate in the healthcare system’s coordinated emergency preparedness program.

If elected, the unified and integrated emergency preparedness program must do all of the following:

Demonstrate that each separately certified facility within the system actively participated in the development of the unified and integrated emergency preparedness program.

Be developed and maintained in a manner that takes into account each separately certified facility’s unique circumstances, patient populations, and services offered.

Demonstrate that each separately certified facility is capable of actively using the unified and integrated emergency preparedness program and is in compliance with the program.

Each HHA must include a unified and integrated emergency plan that meets the requirements of paragraphs (a)(2), (3), and (4) of this section.  The unified and integrated emergency plan must also be based on and include all of the following:

(i) A documented community-based risk assessment, utilizing an all hazards approach.

(ii) A documented individual facility based risk assessment for each separately certified facility within the health system, utilizing an all hazards approach.

Include integrated policies and procedures that meet the requirements set forth in paragraph (b) of this section, a coordinated communication plan and training and testing programs that meet the requirements of paragraphs (c) and (d) of this section, respectively.

In Conclusion

The emergency preparedness standard is very comprehensive.  However, sound, timely planning is critical in order to be prepared in times of crisis.  For further training on this standard and others that are included in the revised CoPs, we offer onsite education sessions, live webinars, DVDs with pre-recorded webinars, and handouts (Power Point presentations) of classes for purchase.  Please feel free to contact us [email protected] or 866-428-4040 for more details.

Southern Web SupportHome Health – New Conditions of Participation – Emergency Preparedness
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