EMERGENCY PREPAREDNESS Meg Stagliano RN, BSN, MBA

Meg Stagliano RN, BSN, MBA Speaker Spot Light Meg Stagliano RN, BSN, MBA Vice President of NJAASC 21 Years Nursing Experience Masters in Business in Healthcare Administration Administrator at Seashore Surgical Institute Mom, wife, & student Meg.stagliano@scasurgery.com Mobile 732-252-7717

Seashore Surgical Institute Facility Spot Light Seashore Surgical Institute Brick, New Jersey Virtua Health System & SCA (Surgical Care Affiliates) 10,000 square feet & 3 OR’s Perform an average of 600 cases/ month Expansion starting in 2018 Eyes*GI*Plastics*Pain*Podiatry*ENT*Urology General*Hand*Cardiology*Vascular

October 1, 2017 Deadliest mass shooting 59 people died 527 injured University Medical Center in Las Vegas opened ASC to treat patients

Objectives Identify components of an emergency preparedness program Discuss methods to conduct a risk assessment Describe the requirements of an emergency plan Describe the requirements for a communication plan Differentiate between Emergency Preparedness training & testing Conduct a table top exercise for a Flood Emergency

Emergency Preparedness Rule §416.54 Ambulatory Surgical Centers (ASCs) September 8, 2016 Federal Register posted the final rule Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers Must comply by November 15, 2017 https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Emergency-Prep-Rule.html

Purpose of Rule Establish national emergency preparedness requirements to ensure adequate planning for both natural & man-made disasters Establish coordination with federal, state, tribal, regional & local emergency preparedness systems Requirements apply to all 17 provider & supplier types Emergency Preparedness is one of the new Conditions for Coverage (CfC)

Emergency Preparedness Program(EPP) Comprehensive approach to meeting the health & safety needs of a patient population Provides facility with guidance on how to respond to emergency situations that could impact the operation of the facility Included natural or man-made disasters Includes an all-hazards risk assessment and emergency planning

Emergency Plan One part of a facility’s emergency preparedness program Provides the framework for risk assessments & continuity of business operations Plan will guide facility’s ability to collaborate with local emergency preparedness officials

EP Program Vs EP Plan Program- the facility’s comprehensive approach to meeting the health & safety needs of it’s patient population during an emergency Plan- the individual components of the program such an emergency plan, policies & procedures, a communication plan, testing & training plans Regardless of what you call it you must have a comprehensive emergency preparedness program that addresses all of the requirements

4 Core Emergency Preparedness (EP) Elements Risk Assessment & Emergency Planning Communication Plan Policies & Procedures Training & Testing

EMERGENCY PREPAREDNESS PROGRAM EMP Mission, Goals & Objectives of organization related to emergency management Risk Assessment & Planning Emergency Operations Plan EOP Structure & processes to respond to & recover from an event Policies & Procedures Communication Plan Training & Testing Training on hire & annually 2 Drills per year: 1 Full Scale Community Individual or TTX

Risk Assessment & Planning

Requirements Develop an emergency plan based on a risk assessment Perform risk assessment using an All Hazards approach Focus on capacities & capabilities Update emergency plan at least annually

Risk Assessment & Emergency Planning Included but not limited to: Hazards likely in geographic area Care-related emergencies Equipment and Power failures Interruption in Communications, including cyber attacks Loss of all/portion of facility Loss of all/portion of supplies

All Hazards Approach Integrated approach to emergency preparedness planning Focuses on capacities & capabilities critical to preparedness for a full spectrum of emergencies or disasters Includes internal emergencies and a man-made emergency (or both) or natural disaster Approach is specific to the location of the provider Focus is on events most likely to occur for specific provider

2 Types of Risk Assessments Community Based Risk Assessment ensures that facilities collaborate with other entities within their community to promote an integrated response to emergency events Facility Based Risk Assessment hazards specific to a facility based on the geographic location; Patient/Resident/Client population; facility type and potential surrounding community assets Facilities must document compliance with both risk assessments

Community Based Risk Assessments CMS allows facilities to adopt community based risk assessments developed by other entities Utilize assessments from public health agencies or regional healthcare coalitions Must use community based assessment in conjunction with conducting their own facility based assessment. If you are adopting community based assessment you must maintain a copy of the community based risk assessment & collaborate with the entity that developed to ensure your facility plan is in alignment.

Facility Based Risk Assessment Individual Assessment based on your facility & location Consider your patient population Consider resources available within your facility & community Does not address every possible threat or risk to a facility Ensures the facility capacity to address a broad range of related emergencies

Examples of Facility Based Disasters Care related emergencies Equipment & utility failures such as power, water & gas Communication interruptions including cyberattacks Loss of a portion or all of a facility Disruptions in normal supplies of essential resources such as food, water, fuel for heating, generators, medications, medical gases & medical supplies

Considerations What business functions are essential to operations during an emergency? What are risks may you reasonable expect to confront? Risks common to your geographic location ex: river flooding Any unforeseen event that has the ability to affect you The extent to which natural or man made emergencies may cause the facility to limit operations Any necessary arrangements with other healthcare facilities to ensure that essential services could be provided during an emergency If the facility provides care in a structure it does not own the facility must confer with the property owner regarding emergency preparedness including plans to continue care if the structure of the building & it’s utilities are impacted

Staffing strategy for identified staff shortages Staffing strategy for a surge capacity if targeted to accept patients during an emergency Alternate care site to transfer patients Back up evacuation plan for circumstances in which nearby facility is also affected by emergency & unable to receive patients

Hazard Vulnerability Analysis

https://www.fema.gov/media-library-data/8ca0a9e54dc8b037a55b402b2a269e94/CPG201_htirag_2nd_edition.pdf

http://www.phe.gov/Preparedness/planning/hpp/reports/Documents/hc-coop2-recovery.pdf

Community Resources

Community All Hazard Mitigation Plan

Business Impact Analysis Method of evaluating the effects various threats may have on the ability of an organization to perform its essential functions Through the BIA that organizations can identify problem areas Identify gaps, weaknesses, vulnerabilities Use the BIA results to support risk management decision making

Components of Emergency Plan Readiness & Preparedness: Develop Continuity of Operations Program (COOP) What functions are critical to continue operations? Plan to maintain functionality in specific areas despite interruptions Chain of Command for authority Facilitate COOP drills and exercises that activate plans in coordination with regional, state and federal plans

Orders of Succession http://www.phe.gov/Preparedness/planning/hpp/reports/Documents/hc-coop2-recovery.pdf

Delegation of Authority

Continuity Facilities

Essential Records Management The facility keeps all essential hardcopy records in a mobile container that can be relocated to alternate sites. In addition, electronic records, plans, and contact lists are maintained by the organization leadership and can be accessed online and retrieved on system hard drives when applicable and appropriate. Access to and use of these records and systems enables the performance of essential functions and reconstitution to normal operations.

Essential Supporting Activities Determine the extent of disruption to health care service delivery Determine if event has caused a complete or partial disruption of health care service delivery Determine if relocation of health care service delivery to alternate care sites is an option for short-term continuation of service Work with local emergency management and regional

Access to Healthcare Workforce Identify medical and nonmedical staffing shortages during response and continuity operations Recall additional staff incrementally to assist in disaster continuity operations Coordinate with contracted staffing agencies to increase availability of critical medical staff

Facility Critical Infrastructure Determine extent of disruption/loss/damage of facility critical infrastructure Electrical System Water System Ventilation Fire Protection System Fuel Sources Medical Gas & Vacuum Systems Communication Infrastructure Prioritize restoration efforts to meet the operational goals of health care service delivery Disseminate reports of critical infrastructure disruption/loss/damage to local emergency management and to state health authorities Advocate for priority service resumption directly to local incident management

Access to Healthcare Supply Chain Full access to the healthcare supply chain including medical & non-medical supplies, pharmaceuticals, blood products, industrial fuels, and medical gases etc. Determine estimated shortfalls identified during the continuity event of needed supplies Prioritize medical and non-medical supply items needed through medical/surgical supply formularies Redirect supplies already within the hospitals supply chain to areas first impacted Activate pre-event supply orders with vendors

Access to Medical/Non-Medical Transport System Fully functional medical & non-medical transportation system that can meet the operational needs of the healthcare sector during the response & continuity phases of an event Determine additional medical/non-medical transportation needs to support response and continuity operations Provide transportation assistance to staff that may need transportation to facility Disseminate requests for transportation assistance to local emergency management

Healthcare Information Systems Fully functional information technology and communications infrastructure that support high availability of the healthcare sector’s data management and information sharing capability. Determine extent of disruption of communication/information technology capabilities at facilities Activate redundant communication capabilities if necessary Coordinate with local/state emergency management to secure priority service restoration to communication/information technology capabilities Coordinate with state health authorities to disseminate critical response and continuity operations information

Policies & Procedures

Assessing Policies & Procedures Review existing P&P for emergency management Develop and implement policies to incorporate based on the emergency plan, risk assessment and communication plan. Policies and procedures must address a range of issues including evacuation plans, procedures for sheltering in place, tracking patients and staff during an emergency. CMS does not specify where the facility house the EP policies

What are Surveyors Looking for? CMS is not requiring a specific format for how a facility should have their Emergency Plans documented and in which order. Upon survey, a facility must be able to provide documentation of these requirements in the plan and show where the plans are located. CMS recommends EP program documents be housed in a central place to facilitate review Review and update policies and procedures at least annually.

Tracking Patients & Staff Facilities must develop policies that include a system to track the location of on-duty staff & sheltered patients in the facilities care during & after an emergency. Facilities are not required to track the location of patients who voluntarily leave or are appropriately discharged Facility should document in medical record if patient leaves in order to answer questions about the patient’s whereabouts Policy should include who is responsible for the tracking of patients & staff ASC is excluded from this requirement if center is closed or cancels appointments in the event of emergency

Safe Evacuation ASCs §416.54(b)(2) Requirements for safe evacuation from the ASC include: (i) Consideration of care needs of evacuees. (ii) Staff responsibilities. (iii) Transportation. (iv) Identification of evacuation location(s) (v) Primary and alternate means of communication with external sources of assistance

Safe Evacuation Plan EP P&P must address safe evacuation from the facility Facilities should consider evacuation protocols for patients, staff, visitors & vendors on site Evacuation Plan should include transportation & potential evacuation locations P&P must address staff responsibilities during evacuations & meeting care & treatment needs of patients

Transportation Service Facility P&P should consider needs of patient population when designating which type of transportation service would be most appropriate Facility should consider a triaging system for potential evacuations. Most critical patients first, followed by those less critical. Prioritize based on acuity, mobility, destination, etc. Who makes triaging decisions?

Sheltering In Place EP P&P must address a means to shelter in place for patients, staff, volunteers & visitors who remain in the facility in alignment with the facility risk assessment Facilities should plan to shelter all persons who remain in the facility in the event an evacuation cannot be executed & sheltering in place is considered a safe alternative P&P should include criteria for selecting patients & staff that would remain sheltered in place Consider structural stability of the facility in relation to disaster

Documentation Requirements EP P&P must address a system of care documentation that preserves patient information, protects confidentiality of patient Surveyors must now review the emergency plan to verify the inclusion of P&P that ensure the medical record documentation system meets the normal requirements during an emergency During an emergency, if a patient requires care that is beyond the capabilities of the ASC, we would expect that ASCs would transfer patients to a hospital with which the ASC has a written transfer agreement CMS recommends facilities review current CfCs for specific details on transfer agreements

Tracking System If ASC stays open during an emergency & winds up transferring patients they would be required to track the location of patients & any staff members If ASCs cancel surgeries and cease operations, it would eliminate the need to track patients & staff

Communication Plan

Goal of Communication Plan During an emergency, it is critical that all providers have a system to contact staff, physicians & other necessary persons Facility must be able to communicate in a timely manner to ensure safe & effective continuation of patient care functions Plan must demonstrate how the facility coordinates patient care within the following: Staff in the facility Across healthcare providers With state & local authorities

Communication Plan Requirements ASCs §416.45(c) The communication plan must include all of the following: Names and contact information for the following: Staff Entities providing services under arrangement Patients’ physicians Volunteers

Communications Policy Facility maintains a robust and effective communications system to provide connectivity to key leadership, and state and federal response and recovery partners. Organization leadership possess mobile, in-transit communications capabilities to ensure continuation of incident specific communications between leadership and partner emergency response points of contact Organizations has signed agreements with other pre-identified alternate care sites

Communication Plan P&P on how to communicate with receiving facility NJDOH transfer agreement Primary & alternate means with External Sources Primary: regular telephone, email, & fax Alternate means for loss or power & phone Ex: satellite phone, ham radio, social networks

Alternate Methods of Communication Plan should address how you will comply with the communication plan standard during events of limited access to standard communications(telephone, internet, cell) Alternate communication methods include satellite phones, CB radios, short wave radios, NOAA weather radio

What will surveyors look at? A means of providing information about the ASC’s needs, and its ability to provide assistance to the local authority having jurisdiction CMS encourages centers to update contact information's throughout the year as staff changes CMS encourages facilities to maintain contact lists electronically & in hard copy format

Alternate Care Sites http://www.phe.gov/Preparedness/planning/hpp/reports/Documents/hc-coop2-recovery.pdf

Emergency Point of Contact

Supply Chain Matrix

Supply Chain Contact List

Memorandum of Understanding/ Mutual Aid Agreement

Sharing & Releasing Information Communication Plan must include a method for sharing patient information & medical documentation with other healthcare providers to maintain continuity of care Plan must include P&P with address in the event of evacuation a means to release patient information while complying with HIPAA privacy rule In the event of evacuation facility must have a communication system in place capable of disseminating accurate information to family members & local officials. CFR 164.510(b)(4) allows facilities to disclose certain patient information in conjunction with disaster relief efforts to notify family members of a patients location and general condition

Training & Testing

Training Goals Develop and maintain training and testing programs, including initial training in policies and procedures. Demonstrate knowledge of emergency procedures and provide training upon hire & at least annually. Delineate responsibilities for all of their facility’s workers in their emergency preparedness plans Training must be consistent with their expected role during an emergency Conduct drills and exercises to test the emergency plan.

Why is training so important? Heighten awareness of a facilities limitations Improve processes Increase safety & preparedness Mitigate some of the negative effects of a disaster through quicker decision making Drills allow facility to demonstrate feasibility & effectiveness of the plan

How to Develop Training Program Consider items that scored high on your risk assessment Look at your emergency plan Training must reflect the site specific risk assessment for facilities that are part of a system Initial training completed by completion of new hire orientation CMS is seeking insightful & meaningful training Modify training each year to include: Most recent exercises Real life emergencies that occurred in the last year Annual review of facility’s emergency program Ex: focus on new evacuation procedures based on issues documented during the last drill & incorporated during the annual program review

Determining the Level of Training CMS allows facility flexibility in determining the level of annual training for any specific individual based on expected roles in an emergency Ex: Housekeeping personnel may be used to assist in patient transport and should receive training in patient transport Ex: Reception area staff will likely be responsible for assisting in sharing patient information & should be educated on downtime forms for medical records Facility may determine that external training is sufficient to meet requirement (ex: staff receive training on radiation exposure from local law enforcement)

Documentation of Training Training Options Computer based training with a written test Self learning packets Instructor led training with question & answer session Include Specific training by each staff member Methods used to demonstrate knowledge of training program content

Annual Testing Conduct 2 exercises to test emergency plan annually Full Scale Community Based Exercise 2nd Full Scale Individual Facility Based Exercise OR a Table Top Exercise All exercises MUST reflect the risk assessment required as part of the facilities emergency plan using an all hazards approach In the event facilities are non-compliant, the same general enforcement procedures will occur as is currently in place for any other conditions or requirements cited for non-compliance. Facilities are expected to meet all Training and Testing Requirements by the implementation date 11/15/17

Full Scale vs Table Top? Full scale exercise may include any operations based exercise: drill, functional or full scale exercise that assess’ a facilities functional capabilities by simulating a response to an emergency that would impact the facility operations or their community. Full scale exercise typically involves multiple agencies & real world scenarios with mock patients, triaging & treatment 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.

Facility-Based: 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 versus a large metropolitan area). Full-Scale Exercise: A full scale exercise is a multi-agency, multijurisdictional, multi-discipline exercise involving functional (for example, joint field office, emergency operation centers, etc.) and/or ‘‘boots on the ground’’ response (for example, firefighters decontaminating mock victims).

Fulfilling the Community Based Exercise Requirement If a facility is unable to identify a full scale community based exercise to participate, it may fulfill this part of the requirement through one of the following: Conducting an individual facility based exercise Documenting an emergency that required you to full activate your emergency plan Conducting a smaller community based exercise with other nearby facilities Facilities are required to have contact information for emergency officials and who they should contact in emergency events We are not requiring official “sign-off” from local emergency management officials

If a community based exercise is not accessible an individual facility based exercise can meet the requirement If a facility participates in their health systems integrated EP program each separate facility must address their individual facility needs & maintain records of individual exercises to demonstrate compliance If no suitable opportunities are available, CMS requires the facility to document which agencies were contacted, staff contacted and date they contacted each agency Facility must maintain documentation of compliance with all training & drills for a minimum of three years

Examples of Disasters • Earthquakes • Tornados • Hurricane • Flooding • Fires • Cyber Security Attack • Single-Facility Disaster (power-outage) • Medical Surge (i.e. community disaster leading to influx of patients) • Infectious Disease Outbreak • Active Shooter

Training Resources

After Action Report (AAR) At a minimum AAR should determine: What was supposed to happen What actually occurred What went well What the facility can do differently or improve upon AAR should include a plan with timelines for incorporating necessary improvements

Analysis & Review Facilities must document lessons learned from TTX’s, full scale exercises & real life emergencies Conduct an after action review process involving facility leadership and critical staff Document lessons learned & necessary improvements in an official actionable after action report (AAR) Demonstrate incorporation of any necessary improvements in your emergency preparedness program & policies Document reporting exercises, AAR, and changes to P&P in board minutes

Summary Emergency plan is one part of the facility's emergency preparedness program EP must include a facility based & community based risk assessment Utilize an all hazards approach Include strategies for addressing emergency events identified by the risk assessment Include documentation of annual review & any updates made to the plan based on the review

Resources

The SCG Website

Resources California Department of Public Health https://www.cdph.ca.gov/Programs/EPO/Pages/BePreparedCalifornia.aspx National Center for Disaster Medicine & Public Health http://ncdmph.usuhs.edu/NewsEvents/Webinars.htm Emergency Preparedness Checklist https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Downloads/SandC_EPChecklist_Provider.pdf

CMS Survey & Certification EP Site https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/index.html Healthcare COOP & Recovery Planning http://www.phe.gov/Preparedness/planning/hpp/reports/Documents/hc-coop2-recovery.pdf Threat and Hazard Identification & Risk Assessment http://www.fema.gov/media-library/assets/documents/26335 Hazard Vulnerability Analysis http://www.phe.gov/Preparedness/planning/mscc/healthcarecoalition/chapter5/Pages/hazards.aspx

Medicare Waivers in Disasters The Social Security Act authorizes Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and social services programs of the Department. It authorizes the Secretary, among other things, to temporarily modify or waive certain Medicare, Medicaid, CHIP, and HIPAA requirements when the Secretary has declared a public health emergency and the President has declared an emergency or a major disaster under the Stafford Act, or a national emergency under the National Emergencies Act. Sanctions may be waived under Section 1135 for the following requirements: Conditions of Participation Licensure Requirements EMTALA Physician Self-referrals HIPAA Regulations Out-of-network payments https://www.cms.gov/About-CMS/Agency-Information/H1N1/downloads/requestingawaiver101.pdf

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