1. EMERGENCY PREPAREDNESS
Meg Stagliano RN, BSN, MBA

2. 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
Mobile

3. 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

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

5. 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

6. Emergency Preparedness Rule
§ 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

7. 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)

8. 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

9. 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

10. 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

11. 4 Core Emergency Preparedness (EP) Elements
Risk Assessment & Emergency Planning
Communication Plan
Policies & Procedures
Training & Testing

13. 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

14. Risk Assessment & Planning

15. 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

16. 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

17. 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

18. 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

19. 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.

20. 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

21. 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

22. 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

23. 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

24. Hazard Vulnerability Analysis

29. Community Resources

30. Community All Hazard Mitigation Plan

32. 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

33. 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

34. Orders of Succession

35. Delegation of Authority

36. Continuity Facilities

37. 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.

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. Policies & Procedures

45. 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

46. 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.

47. 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

48. 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

49. 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

50. 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?

51. 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

52. 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

53. 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

54. Communication Plan

55. 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

56. 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

57. 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

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

59. 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

60. 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

61. Alternate Care Sites

62. Emergency Point of Contact

63. Supply Chain Matrix

64. Supply Chain Contact List

65. Memorandum of Understanding/ Mutual Aid Agreement

66. 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 (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

67. Training & Testing

68. 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.

69. 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

70. 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

71. 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)

72. 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

73. 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

74. 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.

75. 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).

76. 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

77. 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

78. 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

79. Training Resources

80. 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

81. 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

82. 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

83. Resources

84. The SCG Website

85. Resources California Department of Public Health
National Center for Disaster Medicine & Public Health
Emergency Preparedness Checklist

86. CMS Survey & Certification EP Site
Healthcare COOP & Recovery Planning
Threat and Hazard Identification & Risk Assessment
Hazard Vulnerability Analysis

87. 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

88. Questions?
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