Understanding & Implementing The CMS Emergency Preparedness (EP) Rule

Transcription

1 Understanding & Implementing The CMS Emergency Preparedness (EP) Rle Nora O Brien, MPA, CEM Cathy Larsen, MA Connect Conslting Services, Inc. October 11, 2017

2 Today s Presenters: Nora O Brien, MPA, CEM, CEO v CPCA staffer from , lanched CCS in 2009 to assist clients with developing emergency management plans, training and drills and exercises; Cathy Larsen, MA, Director of Planning and Development v Former ExecNve Director of Sothern Trinity Health Center and years of healthcare emergency management planning. InternaNonal Search & Resce Emergency Responder. AAPCHO Training: Understanding & Implementing the CMS Emergency Preparedness (EP) Rle October 11,

3 Agenda 1. Welcome & Overview 2. CMS Emergency Preparedness Final Rle 3. Where to Begin? 4. Implementation Strategies: Tools & Tips 5. Q & A AAPCHO Training: Understanding & Implementing the CMS Emergency Preparedness (EP) Rle October 11,

4 CMS Emergency Preparedness Rle On September 8, 2016, the Centers for Medicare and Medicaid (CMS) finalized a rle 1 to: 1. Establish consistent emergency preparedness reqirements for health care providers parncipanng in Medicare and Medicaid 2. Increase panent safety dring emergencies, and 3. Establish a more coordinated response to natral and man-made disasters CFR AAPCHO Training: Understanding & Implementing the CMS Emergency Preparedness (EP) Rle October 11,

5 CMS Reqirement Emergency Preparedness for FQHCs/RHCs The reqirements are focsed on three key essentials necessary for maintaining access to healthcare dring disasters or emergencies: 1. Safegarding Hman Resorces 2. Maintaining Bsiness Continity 3. Protecting Physical Resorces AAPCHO Training: Understanding & Implementing the CMS Emergency Preparedness (EP) Rle October 11,

6 Key Components: 3 Years in Development (Not new) Rle Issed: September 8, 2016 Rle Pblished: September 16, 2016 Rle EffecNve: November 16, 2016 ImplementaNon Reqired By: November 15, Reqirements: 1. Develop Emergency Plan based on a Risk Assessment 2. Develop Policies and Procedres 3. Create CommnicaNon Plan 4. Condct Training & Plan TesNng AAPCHO Training: Understanding & Implementing the CMS Emergency Preparedness (EP) Rle October 11,

7 CMS Reqirement Emergency Preparedness for FQHCs/RHCs Sccessfl Adoption: 1. Anticipate and Plan sing All-Hazards approach 2. Rapidly respond as a facility 3. Integrate with local pblic health and emergency management agencies and healthcare coalitions response activities and rapidly recover following the disaster. AAPCHO Training: Understanding & Implementing the CMS Emergency Preparedness (EP) Rle October 11,

8 Step 1: Remain CALM! AAPCHO Training: Understanding & Implementing the CMS Emergency Preparedness (EP) Rle October 11,

9 Step 2: Remember Step 1 Then Keep It SIMPLE! Program Components: Program Mgmt Training & Exercises CommnicaNons Plan Policies & Procedres Emergency Plan AAPCHO Training: Understanding & Implementing the CMS Emergency Preparedness (EP) Rle October 11,

10 1. Emergency Preparedness Plan CMS Reqirement: The FQHC/RHC mst establish and maintain an emergency preparedness plan that mst be reviewed, and pdated at least annally. The Plan Mst: 1. Be based on a facility-based and commnity-based all hazards risk assessment; 2. Inclde strategies for addressing emergency events idennfied in the risk assessment; 3. Address panent poplanon, inclding, bt not limited to, the type of services the RHC/FQHC has the ability to provide in an emergency; and connnity of operanons, inclding deleganons of athority and sccession plans; 4. Inclde a process for cooperanon and collaboranon with local, tribal, regional, State, and Federal emergency preparedness officials. AAPCHO Training: Understanding & Implementing the CMS Emergency Preparedness (EP) Rle October 11,

11 Risk Assessment CMS Reqirement: The emergency plan mst be based on and inclde a docmented, facility-based and commnity-based risk assessment, 5lizing an all-hazards approach. A Hazard Vlnerability Analysis (HVA) tool created by Kaiser Permanente pinpoints: Hazards and/or vlnerabilines that need yor aiennon; AcNons that might be taken to redce the impact of those hazards; What resorces are likely to be needed to mingate and prepare for hazards. AAPCHO Training: Understanding & Implementing the CMS Emergency Preparedness (EP) Rle October 11,

12 Hazard Vlnerability Analysis Process to help FQHC/RHC OrganizaNons evalate their vlnerability to specific hazards Pts each hazard in perspecnve by sing categories: 1. Probability of the Hazard Occrring; 2. Impact of the Hazard: a. Hman Impact; b. Property Impact; c. Bsiness Impact. 3. Preparedness of yor organizanon; 4. Ability to Response to the Hazard: a. Internal Response; b. External Response. AAPCHO Training: Understanding & Implementing the CMS Emergency Preparedness (EP) Rle October 11,

13 Hazard Vlnerability Analysis (HVA) Natral Hazards Wild Fire Droght Earthqake (> 5.0) Snow Fall Landslide Blizzard Severe Thnderstorm Ice Storm Tidal Wave Temperatre Extremes Flood, External Dam Inndation Hrricane Tornados AAPCHO Training: Understanding & Implementing the CMS Emergency Preparedness (EP) Rle October 11,

14 Hazard Vlnerability Analysis (HVA) Technological Hazards Information Systems Failre Fel Shortage Commnications Failre Sewer Failre Fire, Internal Natral Gas Failre Electrical Failre Fire Alarm Failre Generator Failre HVAC Failre Total Elevator Failre Data Compromise Water Failre Flood, Internal Denial of Services (compter/network/ website) AAPCHO Training: Understanding & Implementing the CMS Emergency Preparedness (EP) Rle October 11,

15 Hazard Vlnerability Analysis (HVA) Hman Hazards Epidemic/Pandemic Bomb Threat Mass Casalty Incident (trama) Civil Distrbance Violent Person Hostage Sitation Train Crash (at facility) Labor Action Terrorism (CBERN) Active Shooter AAPCHO Training: Understanding & Implementing the CMS Emergency Preparedness (EP) Rle October 11,

16 The Emergency Preparedness Plan Mst INCLUDE strategies for addressing emergency events identified by the Risk Assessment (HVA) WHAT??? The Plan Shold Describe: WHO will do WHAT, as well as WHEN; With what RESOURCES; and, By what AUTHORITY. BEFORE, DURING, AND IMMEDIATELY AFTER AN EMERGENCY. AAPCHO Training: Understanding & Implementing the CMS Emergency Preparedness (EP) Rle October 11,

17 The Emergency Preparedness Plan Mst 17 Address Patient Poplation & Type of Service; Continity of Operations (COO); Delegation of Athority & Sccession Plans (accomplished throgh ICS). October 11, 2017 AAPCHO Training: Understanding & Implementing the CMS Emergency Preparedness (EP) Rle 17

18 Policies & Procedres Additionally: The Policies & Procedres mst address management of medical and nonmedical emergencies, inclding, bt not limited to: Fire; eqipment, power, or water failre; care-related emergencies; and natral disasters likely to threaten the health or safety of the patients, staff, or the pblic. Policies and procedres mst be reviewed and pdated at least annally. October 11, 2017 AAPCHO Training: Understanding & Implementing the CMS Emergency Preparedness (EP) Rle 18

19 2. Policies & Procedres CMS Reqirement: The FQHC/RHC mst develop and implement emergency preparedness policies and procedres, based on the emergency plan, risk assessment and commnicanons plan. Policies and procedres mst be reviewed and pdated at least annally and mst address: 1. Safe EvacaNon 2. A means to Shelter in Place 3. A system of medical docmentanon that preserves panent informanon, protects confidennality of panent informanon, and secres and maintains the availability of records 4. The Use of Volnteers AAPCHO Training: Understanding & Implementing the CMS Emergency Preparedness (EP) Rle October 11,

20 3. Emergency Commnications Plan CMS Reqirement: The FQHC/RHC mst develop and maintain an emergency preparedness commnicanons plan that complies with Federal, State and local laws and mst be reviewed and pdated annally. It mst inclde: 1. Names and contact info for staff, contracted ennnes, parncipanng physicians, other FQHCs and volnteers; 2. Contact informanon for Federal, State, tribal, regional, local emergency preparedness staff and other sorces of assistance; 3. Primary and alternate means of commnicanon; 4. A means of providing informanon abot the general condinon and locanon of panents nder the facility's care; 5. A means of providing informanon abot the RHC/FQHC's needs, and its ability to provide assistance to jrisdicnonal athority. AAPCHO Training: Understanding & Implementing the CMS Emergency Preparedness (EP) Rle October 11,

21 4. Training and Plan Testing CMS Reqirement: FQHC/RHC mst condct and docment annal training and test plans with 2 exercises annally: 1. Training: Condct and docment ininal and annal training on yor emergency preparedness policies and procedres to all staff, parncipants, volnteers, and contractors; 2. Exercises: Mst condct and docment two exercises annally: One mst be a commnity-based Fll-Scale Exercise; The other exercise can be a second Fll-Scale or Tabletop Exercise. AAPCHO Training: Understanding & Implementing the CMS Emergency Preparedness (EP) Rle October 11,

22 CMS Reqirement Emergency Preparedness for FQHCs/RHCs Emergency Prep Testing Reqirements As the term fll-scale exercise may vary by sector, facilines are not reqired to condct a fll-scale exercise as defined by FEMA or DHS s Homeland Secrity Exercise and EvalaNon Program (HSEEP); For the prposes of this reqirement, a fll scale exercise is defined and accepted as any operanons-based exercise (drill, fncnonal, or fll-scale exercise) that assesses a facility s fncnonal capabilines by simlanng a response to an emergency that wold impact the facility s operanons and their given commnity; A fll-scale exercise is also an operanons-based exercise that typically involves mlnple agencies, jrisdicnons, and disciplines performing fncnonal or operanonal elements. AAPCHO Training: Understanding & Implementing the CMS Emergency Preparedness (EP) Rle October 11,

23 Tips, Tools & Strategies: 3 Key Components to Developing Sccessfl Emergency Preparedness Programs: 1. Leadership Spport 2. MlN-Discipline (clinical and non-clinical) Team Approach 3. IntegraNon with ExisNng Programs AAPCHO Training: Understanding & Implementing the CMS Emergency Preparedness (EP) Rle October 11,

24 Tips, Tools & Strategies: Qestions & Discssion

25 Now what? Where do I start? AAPCHO Training: Understanding & Implementing the CMS Emergency Preparedness (EP) Rle October 11,

26 Now That I m Here, Where am I? - Janice Joplin Well, that depends on where yo are. AAPCHO Training: Understanding & Implementing the CMS Emergency Preparedness (EP) Rle October 11,

27 Connect Conslting Services Self-Assessment Tool Step 1: Basic Understanding of the CMS EP Rle; Step 2: Self-Assessment EvalaNon of Where Yo Are ; Step 3: Developing a Road Map of geong to Compliance ; Step 4: Maintaining Compliance. AAPCHO Training: Understanding & Implementing the CMS Emergency Preparedness (EP) Rle October 11,

28 Self-Assessment Tool Where is YOUR organization in terms of CMS EP compliance? AAPCHO Training: Understanding & Implementing the CMS Emergency Preparedness (EP) Rle October 11,

29 FQHC/RHC Emergency Preparedness Self-Assessment Tool AAPCHO Training: Understanding & Implementing the CMS Emergency Preparedness (EP) Rle October 11,

30 Tips, Tools & Strategies: Hands-On Exercise

31 AAPCHO Training: Understanding & Implementing the CMS Emergency Preparedness (EP) Rle October 11,

32 Connect Conslting Services CMS Rle Assistance DO IT YOURSELF PLANNING TOOL-BOX: FQHC CMS Gidance Docment Self-Assessment Tools & Crosswalk Emergency Preparedness Plan Template Hazard Response Plan Templates (hrricane, earthqake, fire, etc.) (4) Policy and Procedre Templates Commnications Plan Template DO IT WITH YOU PACKAGE: Do It Yorself Planning Tool-Box Do It Yorself Training & Exercise Tool-Box Twenty-five (25) Hors of technical emergency planning, training, or exercise spport On-Site Evalation & Compliance Review Report Design and Condct a Virtal Two-hor CMS Tabletop Exercise DO IT FOR YOU PACKAGE: Provides a complete and trn-key soltion: On-Site Evalation with Compliance Review Report Risk-Assessment & Comprehensive Emergency Management Plan CMS Compliant Policies and Procedres Virtal Two-hor Tabletop Exercise Fll-Scale Exercise AAPCHO Training: Understanding & Implementing the CMS Emergency Preparedness (EP) Rle October 11,

33 Contact Us! Ø Ø Ø Nora O Brien, MPA, CEM, Chief Exective Officer Nora@ConnectConslting.biz Mobile: (916) Cathy Larsen, MA, Director of Planning & Development Cathy@ConnectConslting.biz Mobile: (916) Connect Conslting Services th Street, Site 202, Sacramento, CA Office: (916) AAPCHO Training: Understanding & Implementing the CMS Emergency Preparedness (EP) Rle October 11, 2017