Thank You For Joining Us THE WEBINAR WILL BEGIN SHORTLY WELCOME Thank You For Joining Us THE WEBINAR WILL BEGIN SHORTLY You will not be able to hear sound through your computer. Dial in through your phone to listen to webinar audio: Conference Number: +1 (646) 307-1001  Access Code: 639-554-273 If you wish to ask a question, use the “Questions” feature in the GoToWebinar control panel. We will create a queue and answer as many as possible following the presentation. For Technical Assistance please contact Janlia Riley at Janlia@constantassociates.com or 424-320-2585

C&A WEBINARS PRESENTS : CMS  Emergency Preparedness  Requirements

CMS Finalizes New Emergency Preparedness Rule CMS finalized new emergency response requirements for healthcare providers participating in the Medicare or Medicaid system. The new rule comes as a response to a string of disasters, natural and man-made, including the recent flooding in Louisiana. Preparation, planning, and one comprehensive approach for emergency preparedness are key. The new rules are intended to plug gaps in CMS’ old emergency preparedness regulations.

Is Your Hospital Prepared? California hospitals are a key element within the disaster medical response system and work collaboratively with local government, other health care providers and other agencies to plan, prepare for and respond to the needs of victims of natural or man-made disasters, bioterrorism, and other public health emergencies. Hospital emergency preparedness is a priority for government at all levels, as well as a key focus of regulatory and accrediting agencies. CHA 2016

Patient Surge Surge Capacity – “the ability to manage increased patient care volume that otherwise would severely challenge or exceed the existing medical infrastructure”. Surge Capability – “the ability to manage patients requiring unusual or very specialized medical evaluation and intervention, often for uncommon medical conditions”.

CMS Survey & Certification Letter 16-38-ALL Memorandum Summary Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers: On September 8, 2016 the Federal Register posted the final rule for Medicare and Medicaid Participating Providers and Suppliers. The regulation goes into effect on November 15, 2016. Health care providers and suppliers affected by this rule must comply and implement all regulations one year after the effective date, on November 15, 2017. Ashley Note: The ASPR documents and the original federal register note that the CMS regulations go into effect as of November 15, 2016 and regulations must be implemented by November 15, 2017.

Federal Register The S & C memo directs organizations to the Federal Register where the full text of the new rules can be found. The Final Rule can be located at: https://www.federalregister.gov/public-inspection

What You Need To Know… Under the old rules, providers were not required to coordinate with other health organizations during an emergency. There was not a requirement for contingency planning and emergency response training for staff. Now, healthcare organizations will need to coordinate their plans with federal, state, regional, and local emergency preparedness systems.

The Rule Requires that HC Providers Meet the Following Four Standards: 1. Emergency plan: Based on a risk assessment, develop an emergency plan using an all-hazards approach focusing on capacities and capabilities that are critical to preparedness for a full spectrum of emergencies or disasters specific to the location of a provider or supplier 2. Policies and procedures: Develop and implement policies and procedures based on the plan and risk assessment 3. Communication plan: Develop and maintain a communication plan that complies with both federal and state law. Patient care must be well-coordinated within the facility, across healthcare providers, and with state and local public health departments and emergency systems 4. Training and testing program: Develop and maintain training and testing programs, including initial and annual trainings

Type Of Provider and Supplier These standards are adjusted to reflect the characteristics of each type of provider and supplier. Example: Hospitals, Critical Access Hospitals, and Long Term Care facilities as well as Federally Qualified Health Centers (FQHCs) will be required to install and maintain emergency and standby power systems based on their emergency plans. Outpatient providers and suppliers such as Ambulatory Surgical Centers and End-Stage Renal Disease Facilities will not be required to have policies and procedures for provision of subsistence needs.

What You Need To Do... Emergency Management leaders to download the full text of the new rules from the Federal Register Conduct a GAP analysis to determine enhancements your program may need Discuss findings with your organization’s EM committee Present findings with executive leadership

Hazard Vulnerability Analysis Identified various potential hazards, threats, and adverse events and assess the impact of potential on the care, treatment and services sustained during an emergency situation. Emergency Management Committee conducts an annual written HVA to identify potential man-made and natural emergencies that could affect demand for services or the ability to provide those services, the likelihood of those events occurring, and the consequences of those events (EM 01.01.01, EP2, EM 03.01.01, EP1) The risk assessment should prioritize the types of hazards likely to occur in your area. In a Joint Commission Survey, this is referred to as the hazard vulnerability analysis (HVA). In this instance CMS specifically suggests that the potential hazard of a cyber-attack be analyzed.

HVA Summary Natural Infrastructure Security Mass Causality Likelihood an event would happen establishing low, medium and high Impact Human Property Business Preparedness Internal External

Emergency Operation Plan The Hospital’s Emergency Operations Plan (EOP) is designed to coordinate communication, resources and assets, safety and security, staff responsibilities, utilities and patient clinical and support activities during an emergency (CAHM, July 2016). Developing a comprehensive EOP Participants should include hospital leadership and leaders of the medical staff. The policies and procedures would be the action steps your team needs to implement in the event of an emergency to manage the situation. Comprehensive and flexible Emergency Operation Plan that guides decision making at the onset of an emergency and as an emergency evolves. The policies and procedures would be the action steps your team needs to implement in the event of an emergency to manage the situation

Communication Detail how your team will communicate to staff, providers, vendors, supplies, and others to ensure that patient care responsibilities can be carried out. Establish back up communication processes and technologies (for example, cell phones, landlines, bulletin boards, fax machines, satellite phones, amateur radios, text messages). Include how the hospital prepares for how it will manage the following: Staff resources: roles and responsibilities Resources and assets Safety and Security Utilities Patient management The process for assigning staff to all essential staff functions

Training and Testing Training and testing will require onboarding and annual training for staff as well as testing through drills. Employees are provided training (i.e. during new hire orientation, distributions monthly training topics, quarterly trainings and department specific training). EM 02.02.07 EP 7 The hospital trains staff for their assigned emergency response roles Rationale ”….Due to the dynamic nature of emergencies, effective training prepares staff to adjust to the changes in the patient volumes or acuity, work procedures or conditions, and response partners within and outside the hospital”

Training and Testing Conduct drills and exercises or participate in actual incidents that test the plan Fire Drills Code Triage: Bi-Annual Disaster Drills with area healthcare facilities or local healthcare coalition Code Pink (Infant/Child Abduction) Code Silver (Active Shooter) Code Blue Bio-Hazardous Incident Cyber attacks: Ransom ware Conduct this in a no-fault learning environment - processes, NOT individuals, will be evaluated Identify the Lessoned Learned Utilize resources such as your HVA to identify areas of improvement within your facility

Thoughts... We Don’t Rise to the Level of Our Expectations, We Fall to the Level Of Our Training - Archilochus

SEVEN BENEFITS OF HOSPITAL PREPAREDNESS Ensures ability to continue core mission by establishing the priority of and sequencing of services that must be continued to maintain essential operations (supply chain, payroll, research) and healthcare delivery (patient care) Provide strategies to develop effective plans and operational recovery strategies Identifies risks and measures that may impact operations during interruption events and disasters Builds financial resilience, mitigates economic impact of interruptions and controls recovery costs and increases market share Improves patient safety, efficiency, availability of critical supplies Exceeds compliance with the increasing cross-section of healthcare emergency management and business continuity standards Protects technology investments and organizational assets

Local and National Resources The final rule also includes a number of local and national resources related to emergency preparedness, including helpful reports, toolkits, and samples. Additionally, health care providers and suppliers can participate in their local healthcare coalitions, which provide an opportunity to share resources and expertise in developing an emergency plan and also can provide support during an emergency. CMS Survey & Certification – Emergency Preparedness webpage: https://www.cms.gov/Medicare/Provider-Enrollment-and- Certification/SurveyCertEmergPrep/index.html

Additional Resources State – California Hospital Association Emergency Preparedness http://www.calhospitalprepare.org/ California Department of Public Health WWW.CDPHREADY.ORG National – The Joint Commission Emergency Management Resources Portal https://.jointcommission.org/emergency management.asp ASPR's CMS Emergency Preparedness Rule Resources https://asprtracie.hhs.gov/cmsrule  CMS.gov MLN Webpage https://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider- Calls-and-Events-Items/2016-10-05-Emergency- Preparedness.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending Local – local Public Health Departments

Additional Training Resources https://cdp.dhs.gov/find-training/healthcare

Additional Training Resources Healthcare Coalition Response Leadership Course https://cdp.dhs.gov/find-training/healthcare/course/MGT-454 Hazardous Materials Operations https://cdp.dhs.gov/find-training/healthcare/course/PER-322

Useful Apps WISER MOBILE REMM

Develop a tool designed specially for your organization Tool Kit Develop a tool designed specially for your organization

THANK YOU! Contact Information Nichole F. D Walker, MA Nichole. Walker, MA Senior Safety Coordinator Emergency Management Chair Riverside University Health System Email: Nwalker@rc-hr.com Mary Drayer, RN, MSN, BSN, CPHQ Healthcare Administrative Surveyor/ Regulatory-Compliance Officer Riverside University Health System-Medical Center M.drayer@ruheslth.org Register to receive information and updates on upcoming C&A Captivate Webinars https://constantassociates.com/ca-captivate-webinar-series-topics/