By Nov. 15, 2017, the Centers for Medicare & Medicaid Services (CMS) expects Medicare- and/or Medicaid-certified nursing homes to be able to demonstrate in survey that they have completed all training and testing requirements in the Emergency Preparedness Requirements Final Rule, said agency officials during the April 27 Emergency Preparedness Requirements Final Rule Training Call. Those requirements include the completion of two exercises. (Access the slide presentation, call transcript, and audio recording here.)
The Emergency Preparedness Final Rule specifically states “that facilities do not require the interpretive guidelines in order to implement these regulatory requirements,” said officials. However, most providers will want to review the advance copy of the brand-new Appendix Z, “Emergency Preparedness for All Provider and Certified Supplier Types,” in the State Operations Manual. Appendix Z, which is available in survey-and-certification memo S&C:17-29-ALL, contains interpretive guidance for surveyors, as well as survey procedures, that can help facilities refine their approach to achieving compliance.
The Emergency Preparedness Final Rule became effective upon publication: Nov. 15, 2016. However, CMS instituted a one-year implementation delay to give affected providers “the opportunity to come into compliance,” said officials. Therefore, the training and testing requirements of the final rule need to be implemented by Nov. 15, 2017. “Facilities must be able to demonstrate completion of the training and testing requirements during surveys that take place starting on Nov. 16 of this year and thereafter,” they explained.
Nursing homes—both skilled nursing facilities (SNFs) and nursing facilities (NFs)—are one of 17 provider and supplier types that must meet the new emergency requirements in the Emergency Preparedness Final Rule as a condition of participation (CoP). If providers are found noncompliant after Nov. 15, 2017, “the same general enforcement procedures will occur as are currently in place for any other conditions or requirements cited for noncompliance,” said officials. “There are no exceptions to this final rule for any providers or suppliers [e.g., rural or small providers/suppliers].”
While enforcement procedures remain the same, “the emergency preparedness requirements will have a set of tags that will be utilized to cite noncompliance for all 17 provider and supplier types included in the final rule,” noted CMS in S&C:17-25-ALL. “The tags for emergency preparedness will be ‘E’ Tags and accessible to both health and safety surveyors and LSC Surveyors. State survey agencies will have discretion regarding whether the LSC or health and safety surveyors will conduct the emergency preparedness surveys.”
The rule has four general provisions:
1. Risk assessment and emergency planning.
2. Policies and procedures.
3. Communication plan.
4. Training and testing.
Training and testing requirements
Nursing homes must develop and maintain an emergency preparedness training and testing program that is based on their risk assessment and emergency plan, policies and procedures, and communication plan. “Training and testing of the emergency plan must take place so that all personnel within the facility know how to respond to emergencies that were identified in the risk assessment,” said officials. Core training and testing requirements are explained in the revised § 483.73(d), Training and Testing, of Part 483—Requirements for States and Long-term Care Facilities, in Title 42 of the Code of Federal Regulations. Note: Also see tags E-0036, E-0037, and E-0039 in Appendix Z.
Here are the basics from tag E-0036 in Appendix Z: “An emergency preparedness training and testing program as specified in this requirement must be documented and reviewed and updated on at least an annual basis. The training and testing program must reflect the risks identified in the facility’s risk assessment and be included in their emergency plan. For example, a facility that identifies flooding as a risk should also include policies and procedures in their emergency plan for closing or evacuating their facility and include these in their training and testing program. This would include, but is not limited to, training and testing on how the facility will communicate the facility closure to required individuals and agencies, testing patient tracking systems and testing transportation procedures for safely moving patients to other facilities. Additionally, for facilities with multiple locations, such as multi-campus or multi-location hospitals, the facility’s training and testing program must reflect the facility’s risk assessment for each specific location.”
For the training component, providers must do the following:
· Provide 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. Note: CMS discussed what the term “training” means in the Round One Emergency Preparedness Frequently Asked Questions (FAQs): “… We expect facilities to delineate responsibilities for all of their facility’s workers in their emergency preparedness plans and to determine the appropriate level of training for each professional role. Therefore, facilities will have discretion in determining what encompasses appropriate training for the different staff positions/roles.”
· Provide emergency preparedness training at least annually.
· Maintain documentation of the training.
· Demonstrate staff knowledge of emergency procedures (e.g., staff can demonstrate such knowledge during annual emergency preparedness training).
For the testing component, nursing homes must conduct exercises to test the emergency plan at least annually, including unannounced staff drills using the emergency procedures, in order to identify gaps and areas for improvement. Required steps as defined in the Final Rule include the following:
· Participate in a full-scale exercise that is community-based or, when a full-scale community-based exercise is not accessible, an individual, facility-based exercise. Note: Appendix Z provides the option of a smaller community-based exercise with other nearby facilities when a full-scale exercise isn’t feasible. During the call, officials also discussed this as an option, counting it as a type of individual, facility-based exercise. Learn more about this option below.
· Conduct an additional exercise that may include, but is not limited to the following:
o A second full-scale exercise that is community-based, or individual and facility-based; or
o 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 nursing home’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the emergency plan as needed.
What ‘annual’ means
Nursing homes must participate in or conduct two exercises at least annually. However, the “annual” testing requirement will not be measured on a calendar year (Jan. 1 – Dec. 31) basis. “‘Annual’ will be considered within 12 months’ timeframe from when the last exercise was completed,” said officials. “For instance, if a facility completed a full-scale exercise on Oct. 1, 2017, then they must complete the two exercises before Sept. 30, 2018.”
Note: If a facility experienced a natural or man-made emergency and had to activate its emergency plan, that would satisfy one of the two annual testing requirements, exempting the facility from engaging in a community or facility-based exercise for one year following the date of the actual emergency event, per these Round Three Emergency Preparedness Frequently Asked Questions (FAQs).
This annual requirement also means that, between the final rule’s effective date (Nov. 15, 2016) and implementation date (Nov. 15, 2017), providers must complete the two required exercises, stressed officials.
Full-scale vs. facility-based
CMS has defined the difference between a full-scale and a facility-based exercise:
· Facility-based. “When discussing the terms ‘all-hazards approach’ and facility-based risk assessments, we consider the term ‘facility-based’ to mean that the emergency preparedness program is specific to the facility,” said officials. “Facility-based includes, but is not limited to, hazards specific to a facility based on the geographic location; patient/resident/client population; facility type; and potential surrounding community assets (i.e. rural area vs. a large metropolitan area).”
· Full-scale exercise. The definition from the definitions list in Appendix Z is as follows: “A full-scale exercise is an operations-based exercise that typically involves multiple agencies, jurisdictions, and disciplines performing functional (for example, joint field office, emergency operation centers, etc.) and integration of operational elements involved in the response to a disaster event, i.e. ‘boots on the ground’ response activities (for example, hospital staff treating mock patients).” Note: Find examples of exercise considerations in these Round Four Emergency Preparedness FAQs.
CMS has received multiple inquires as to what “community” means in terms of a community-based full-scale exercise. However, the final rule (page 63892) “specifically states that we don’t define community to afford providers and suppliers the flexibility to develop emergency exercises that reflect their risk assessments,” said officials. “This can mean multi-state regions. The goal behind the full-scale exercises and broad term of ‘community’ is to ensure healthcare providers collaborate with other entities and, when possible, promote an integrated response to disasters. By allowing this flexibility, especially taking into account rural areas, facilities are able to more realistically reflect the risks and composition of their communities. Additionally, facilities should actively engage their emergency officials and also health care coalitions in their states to see if there are any opportunities for community-wide exercise. This will allow for the facility to assess their emergency plan but, also, better understand how they can contribute during an emergency in their community.”
Facilities that are unable to coordinate a full-scale community-based exercise have other options for meeting that requirement. These are explained in tag E-0039 in Appendix Z:
Facilities that are not able to identify a full-scale community-based exercise, can instead fulfill this part of their requirement by either conducting an individual facility-based exercise, documenting an emergency that required them to fully activate their emergency plan, or by conducting a smaller community-based exercise with other nearby facilities. Facilities that elect to develop a small community-based exercise have the opportunity to not only assess their own emergency preparedness plans but also better understand the whole community’s needs, identify critical interdependencies and or gaps and potentially minimize the financial impact of this requirement. For example, a LTC facility, a hospital, an ESRD facility, and a home health agency, all within a given area, could conduct a small community-based exercise to assess their individual facility plans and identify interdependencies that may impact facility evacuations and or address potential surge scenarios due to a prolonged disruption in dialysis and home health care services. Those that elect to conduct a community-based exercise should make an effort to contact their local/state emergency officials and healthcare coalitions, where appropriate, and offer them the opportunity to attend as they can provide valuable insight into the broader emergency planning and response activities in their given area.
Facilities that conduct an individual facility-based exercise will need to demonstrate how it addresses any risk(s) identified in its risk assessment. For example, an inpatient facility might test their policies and procedures for a flood that may require the evacuation of patients to an external site or to an internal safe “shelter-in-place” location (e.g. foyer, 61 cafeteria, etc.) and include requirements for patients with access and functional needs and potential dependencies on life-saving electricity-dependent medical equipment. An outpatient facility, such as a home health provider, might test its policies and procedures for a flood that may require it to rapidly locate its on-duty staff, assess the acuity of its patients to determine those that may be able to shelter-in-place or require hospital admission, communicate potential evacuation needs to local agencies, and provide medical information to support the patient’s continuity of care.
A small community-based exercise may be “less burdensome” for providers within a given area, noted officials. “Ultimately, though, it’s up to the facility to demonstrate compliance upon survey.”
Tag E-0039 in Appendix Z also clarifies what documentation is needed to support the lack of a full-scale community exercise: “Facilities are expected to contact their local and state agencies and healthcare coalitions, where appropriate, to determine if an opportunity exists and determine if their participation would fulfill this requirement. In doing so, they are expected to document the date, the personnel and the agency or healthcare coalition that they contacted. It is also important to note that agencies and or healthcare coalitions conducting these exercises will not have the resources to fulfill individual facility requirements and thus will only serve as a conduit for broader community engagement and coordination prior to, during and after the full-scale community-based exercise. Facilities are responsible for resourcing their participation and ensuring that all requisite documentation is developed and available to demonstrate their compliance with this requirement.” Note: Also see S&C:17-21-ALL.
The basic definition of a table-top exercise (TTX) is “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,” said officials.
Here’s the official definition in Appendix Z: “A tabletop exercise involves key personnel discussing simulated scenarios in an informal setting. TTXs can be used to assess plans, policies, and procedures. A tabletop exercise is a discussion-based exercise that involves senior staff, elected or appointed officials, and other key decision making personnel in a group discussion centered on a hypothetical scenario. TTXs can be used to assess plans, policies, and procedures without deploying resources.”
Note: The California Association of Health Facilities’ April 2009 publication Evacuation Drill for Long-term Care Facilities contains plans for a four-step simulated evacuation using a TTX. Find additional resources at ASPR-TRACIE’s Long-term Care Facilities Collection and more critical definitions involved in the final rule here.
Integrated health system options
The Emergency Preparedness Final Rule allows qualifying facilities to choose to participate in an integrated health system emergency plan. “There is a great deal of confusion [about] what constitutes a healthcare system as opposed to a certified [provider] that has many locations,” noted officials. “A healthcare system is made up of many separately certified facilities, meaning [they have] separate CCN numbers.”
If one provider has multiple locations operating under the same CCN, that’s not an integrated healthcare system, said officials. Consequently, all of those locations “have to be in alignment with one emergency plan under that [provider’s] plan.” However, in an integrated healthcare system where the providers are separately certified and have their own CCNs, “those different facilities within that system can opt to come together and put an integrated plan together through the system,” they said.
Note: Nursing homes can find their specific requirements in § 483.73(f), Integrated Healthcare Systems, of Part 483—Requirements for States and Long-term Care Facilities, in Title 42 of the Code of Federal Regulations. Also see tag E-0042 in Appendix Z.
· CMS Emergency Preparedness Rule website: Includes a state-by-state listing of healthcare coalitions, a sample facility transfer agreement, FAQs, definitions, and other resources.
· ASPR-TRACIE technical assistance center: This page provides free assistance with technical questions, such as “How do I draft a communication plan?” or “Can I get a template for risk assessment?”
· CMS Emergency Preparedness e-mail box: SCGEmergencyPrep@cms.hhs.gov.
For permission to use or reproduce this article in full or in part, please submit a permissions form.