I have started to review the new CMS Final Rule on Emergency Preparedness. Here are some of the highlights, along with my comments…
Comments and Observations in the CMS EM Final Rule
1) CMS says there are three key essential requirements for maintaining access to healthcare services during emergencies:
- Safeguarding human resources
- Maintaining business continuity
- Protecting physical resources
2) CMS has identified four core elements that are central to emergency preparedness program:
- Risk assessment and emergency planning: CMS requires all facilities to perform a risk assessment that uses an “all hazards” approach prior to establishing an emergency plan. (NOTE: This is the HVA currently required)
- Policies and procedures: CMS requires the facility to develop and implement policies and procedures that support the execution of the emergency plan.
- Communication plan: CMS is requiring the facility to develop and maintain an emergency preparedness communication plan.
- Training and testing: CMS is requiring the facility to develop and maintain an emergency preparedness training and testing program. (NOTE: This applies to all staff and must include annual refresher training).
3) CMS states in their Final Rule that “Currently, in the event of a disaster, healthcare facilities across the nation will not have the necessary planning and preparation in place to adequately protect the health and safety of the patients. In addition, we believe that the current regulatory patchwork of federal, state, and local laws and guidelines, combined with various accrediting organizations’ emergency preparedness standards, falls short of what is needed for healthcare facilities to be adequately prepared for a disaster.” (OUCH! CMS is saying The Joint Commission’s EM standards and HFAP’s EM standards are inadequate and ‘falls short’ for healthcare facilities to be adequately prepared for a disaster. I don’t agree with that comment.)
4) CMS defines an “emergency” or a “disaster” as an event that can affect the facility internally as well as the overall target population or the community at large. Emergencies can be internal, man-made, or natural events, and can be small or large events.
5) CMS states that their new emergency preparedness requirements focus on continuity of operations, not recovery of operations. Facilities may choose to include recovery of operations planning in their emergency preparedness plan, but they have not made recovery of operations planning a requirement.
6) CMS states facilities are required to track the location of patients and staff in the facility’s care during the emergency.
7) CMS says individual physicians are not required, but are encouraged, to develop and maintain emergency preparedness plans. In addition, physicians that are employed by the facility and all new and existing staff must participate in emergency preparedness training and testing. CMS has not mandated a specific role for physicians during an emergency or disaster event, but they expect facilities to delineate responsibilities for all of their facility’s workers in the emergency preparedness plans and to determine the appropriate level of training for each professional role.
8) Based on a response they received during the public comment period, CMS has changed their proposed rule to allow integrated health systems to have a coordinated emergency preparedness program. CMS revised their proposed requirements by adding a separate standard to the CoPs and CfCs. This separate standard will allow any separately certified healthcare facility that operates within a healthcare system to elect to be a part of the healthcare system’s unified emergency preparedness program.