1. Emergency Operations Plan (EOP) Review

2. Objectives: Review Healthcare Preparedness Program Structure
Recognize Healthcare Preparedness & Response Capabilities
Detail the CMS Emergency Preparedness Rule
Understand accreditation requirements of the EOP

3. Things to Remember… EOPs Organize into one manual and tab each section
Have a limited number of hard copies
Have a distribution page
Have a changes page
Use job aids and checklists that coincide with each specific type of incident identified in the risk assessment
It should be specific to your facility

4. CMS Emergency Preparedness Rule
Overview and impacts

5. CMS Compliance Centers for Medicare & Medicaid Services
Conditions of Participation (CoPs) and Conditions for Coverage (CfCs)
Health and safety regulations
Must be met by all Medicare & Medicaid- participating providers and suppliers.
Conditions of reimbursement.
The EP Rule’s purpose is to:
Enhance patient safety during an emergency.
Enhance healthcare delivery system resilience.

6. Who is Impacted? Hospitals
Religious Nonmedical Health Care Institutions
Ambulatory Surgical Centers
Hospices
Psychiatric Residential Treatment Facilities
All-Inclusive Care for the Elderly (PACE)
Transplant Centers
Long-Term Care (LTC) Facilities
Intermediate Care Facilities for Intellectually Disabled
Home Health Agencies
Outpatient Rehab
Critical Access Hospitals
Community Mental Health Centers
Organ Procurement Organizations
Rural Health Clinics
End Stage Renal Disease Facilities (Dialysis)

7. Goal of EP Update Goal of EP Rule Updates:
Address healthcare system gaps.
Establish consistent emergency preparedness practices across provider & supplier types.
Encourage emergency coordination with region & localities.

8. Four Requirements Apply to All Provider Types

9. Risk Assessment & Planning
Perform risk assessment using an “all-hazards” approach.
Update annually
Risk Assessment to include:
Care-related emergencies
Equipment and Power Failures
Communications interruption, including cyberattacks
Loss of all/portion of facility or clinical supplies

10. Risk Assessment, contd.
Develop an emergency plan (updated annually) based on the risk assessment.
Key elements:
Integrated approach- demonstrate ability to address a broad range of hazards.
Addresses shelter-in-place/evacuation
Business Continuity & Continuity of Care
Collaboration with local/regional/state Emergency Mgmt

11. Policies & Procedures
Develop and implement policies and procedures based on the emergency plan and risk assessment.
Policies and procedures must address a range of issues including subsistence needs, evacuation plans, procedures for sheltering in place, mutual aid, patient tracking, medical records, etc.
Review and update policies and procedures at least annually.

12. Assumptions Scenarios
Single Facility / Isolated Incident (e.g., Fire, Loss of Emergency Power);
Single Facility / Local or Area-wide Incident (e.g., Flooding, Ice Storm, Blizzard);
Multiple Facility / Statewide or Regional Incident (e.g., Derecho, Hurricane, Tornado).

13. Incident Management Background
CMS EP Rule
Internal Emergency Operations Plan
National Preparedness System
NIMS
Nursing Home Incident Command System
LTC-MAP
Pg. 7-Internal Emergency Operations Plan

24. Communication Plan
Develop a communication plan that complies with both Federal and State laws.
Coordinate patient care within the facility, across health care providers, and with emergency management systems.
Review and update plan annually.

25. Communication Plan, contd.
Communications Plan must include:
Names/Contact info for stakeholders
Primary and alternate means of communicating with stakeholders
Process/method for sharing medical records and patient information
Process for sharing logistical information such as census, needs, and ability to provide assistance to other facilities.

26. Training & Testing Program
Develop and maintain training and testing programs.
Facilities encouraged by CMS to engage local/state EM and health care coalitions to meet this requirement.
Training program must include:
Initial EP training for new & existing staff, individuals providing services on behalf of facility, and volunteers (consistent with their expected roles).
Documentation of training activities
Provision of annual update training for all staff.

27. Training & Testing Program
Testing (Exercise) Program must include:
Annual exercises to test emergency plans
Tabletop Exercise (recommends HSEEP, but not required)
Community-based Full-Scale Exercise
If full-scale with community not possible, document why and conduct individual facility-based exercise.
Facility is exempt from full-scale requirement for 1 year if an actual or man-made emergency results in activation of the emergency plan.
Documentation required

28. Facility-Specific Rules
Outpatient providers not required to have policies on provision of subsistence needs.
Home Health Agencies and hospices required to inform local EMA of patients in need of evacuation during an emergency.
Long-Term Care and residential Psych facilities must share emergency plan information with residents & their family members.

29. Facility-Specific Rules
Outpatient providers not required to have policies on provision of subsistence needs.
Home Health Agencies and hospices required to inform local EMA of patients in need of evacuation during an emergency.
Long-Term Care and residential Psych facilities must share emergency plan information with residents & their family members.
Additional requirements for Emergency Power and Standby Systems for hospitals, critical access hospitals, and Long-Term Care

30. Expectations for Emergency Management
NOT local EMA’s responsibility to ensure or assist with successful certification.
Local EM’s CAN expect entities to contact them about:
Obtaining copies of jurisdictional HVA or THIRA
Plan/policy integration
Engaging in training/exercise opportunities
Basic information on emergency preparedness and healthcare system preparedness

31. Expectations for Emergency Management
EMAs are not required to certify plans!
EMAs (collaborate with CVEMA?) should develop a standard level of service for requesting facilities:
Standard One-Pager
Set platform for relationships and collaboration despite limited resources
Encourage collaboration with Public Health and Healthcare Coalition

32. Questions? Pete Svoboda MVP Coordinator
Central Virginia Healthcare Coalition
RHCC 24/7 Activation: