1. Hospital Regulatory Issues Bud Pate Director of West Coast Operations

2. Hospital Regulatory Considerations State Department of Health / Licensing CMS Conditions of Participation Accreditation Rules

3. State DHS The Bad News Regulations are incomplete, dated and inflexible The Good News There’s a “get out of jail free” card: Title 22 sections 70741 and 70737

4. 22 CCR 70741: Disaster and Mass Casualty Program This section provides a mechanism for the planned and appropriate use of staff and space for the unusual situation If appropriately written and implemented (with notification to DHS via 70737), the DMC / Emergency Preparedness plan allows the hospital to do what is necessary while maintaining continuous compliance with the regulations.

5. Is Approval Necessary? No, just notification. 22 CCR 70737 However, communication (and the approach to communication) should be excellent and ongoing Refer to mass casualty program Remember to notify CMS if: Overflow into distinct part: e.g. SNF or Rehabilitation Unit. Keep track of beginning and end

6. Expectations for the Disaster and Mass Casualty Program Best reference is JCAHO … post-Katrina update to standards Incident Command Define Overflow locations Separation of flow Temporary / volunteer staffing

7. JCAHO July 1, 200 HR.1.35 Non-LIP Volunteers MS.4.110 LIP Volunteer EC.4.10 Drills