CMS-Compliant Emergency Preparedness & Communications Plan

“Some emergencies that began keeping us up at night were things we used to look at as ‘not going to happen’ or ‘probably won’t happen’—events that have increasingly occurred in recent years and affected VNS Health’s ability to conduct business,” says Lauren Campbell, the organization’s Director of Emergency Preparedness. With threats increasing, employees started to feel less secure, and leaders felt less prepared to engage everyone in an effective emergency response.

“There are a lot of people across our organization who could help expedite our response efforts in an emergency, but without a clear process at the time, it was difficult to educate them on their role in the moment. In many cases, we wouldn’t figure these things out until we were deep into an event,” Campbell explains.

CMS Emergency Preparedness Guidelines

The Centers for Medicare & Medicaid Services (CMS) requires all Medicare and Medicaid-participating providers and suppliers to have an emergency preparedness plan. The purpose of the Emergency Preparedness Rule is

“To establish national emergency preparedness requirements to ensure adequate planning for both natural and man-made disasters and coordination with federal, state, tribal, regional, and local emergency preparedness systems.”

4 core elements of CMS emergency preparedness

To be compliant with the emergency preparedness guidelines, CMS requires that your plan consists of four integral parts, all of which we cover in detail below:

1. Risk assessment and emergency planning
2. Communication plan
3. Policies and procedures
4. Training and testing

1. CMS-Compliant Risk Assessment and Emergency Planning

To prepare for potential threats to your organization, you need to have a clear understanding of the risks. So, the first step toward CMS compliance and comprehensive preparedness is a risk or threat assessment. This assessment can also assist facilities in preparing for a Joint Commission survey and maintaining accreditation or certifications. We have a fillable template available for download, and you can also download the CMS checklist to help you navigate the assessment process.

First, gather all relevant information, including but not limited to

• State and local emergency planning regulations and requirements
• Facility personnel names and contact information
• Contact information of local and state emergency managers
• Specific information about the characteristics and needs of the individuals being cared for
• A facility organization chart
• Building construction details

Consider all hazards

Emergency plans should encompass an all-hazards approach. An all-hazards approach takes into account all man-made and natural disasters and emergencies that can strike a facility. Types of hazards can include:

• Care-related emergencies
• Fires
• Active shooters
• Equipment and power failures
• Interruptions in communication
• Loss of a portion or all of a facility

Your emergency plan should determine the specific action to be taken for each hazard. Such actions should include:

• Appointed staff responsible for executing the plan and their duties
• Description of supplies, equipment, and maintenance needed to sustain operations and deliver care (3–10 days worth of supplies is recommended according to the U.S. Department of Health and Human Services).
• Continuity of Operations Plan (COOP). Even if a facility may not be in harm’s way, the suppliers, utility providers, or staff members might be.
• Efficient communication procedures to receive emergency warning/alerts and outwardly communicate with staff, families, and patients during a critical situation.

You should consider the way your organization will want to communicate around these different types of events. Simply planning how to communicate will leave you to figure out exactly what you want to say when disaster strikes. Instead, craft your messaging and communications plan as a whole before the event happens.

A mass notifications software solution can help you organize the way you plan for and communicate around these events. Having a place to store your contact records and communications templates will save your organization time and frustration.

Prepare a shelter-in-place response

Transporting patients during extreme or hazardous conditions is risky. Evacuation for medical patients should only be taken if the shelter-in-place has greater risks than evacuation. To develop an effective shelter-in-place plan:

• Determine whether the facility is strong enough to withhold severe weather conditions
• Determine if the building can be secured from hazards
• Establish procedures on how and when to communicate with emergency management agencies
• Maintain sufficient resources for the facility (power, water supply, food, medical supplies, etc.)

Establish evacuation response plans

All staff should know the primary, as well as the alternate, evacuation routes from the building. Once a standard route is established, there needs to be an effective plan in place. Top items your plan should include

• An assigned individual who is responsible for running evacuation plans
• Pre-determined evacuation locations at ‘”like’” facilities. Ensure one facility is at least 50 miles away in case the first option is unable to accept evacuees
• Pre-designed maps with identified evacuation routes and travel time
• Food and water supply designated for evacuation
• Fixed logistics to transport medications
• Procedures for safely transporting resident/patient medical records
• Set method created to account for all individuals during and after the evacuation
• Procedure describing missing patients/residents during an evacuation
• Determine how residents will be identified during an evacuation (name, social security number, photograph, date of birth, etc.) and how this information, along with medication/medical equipment, will be secured
• Document and report final re-location details to the clearinghouse established by the state or partnering agency

Coordinate preparedness plans with transportation and vendors

Obtain assurances with transportation vendors and other contractors in your emergency plan who can fulfill their commitments in a time of disaster. Ensure your contract with the correct type of transportation and vendors that will fit your facilities’ criteria. Additionally, collaborate with local emergency management agencies such as EMS, police, and fire departments to ensure the development of an effective emergency plan.

It is also important to note that as a healthcare facility, staff and volunteers employed by your chosen vendors and facilities should be trained on the particular areas and conditions that apply to your facility. The goal here is to help minimize transfer trauma.

Create a facility re-entry plan

Disasters can cause a lot of upheaval to facilities. It is essential to have a plan when re-entering the facility to ensure inspection and safety are up to par and no harm is to come.

• Assign who will authorize re-entry
• Layout the inspection requirements
• Decide how it will be determined when it is safe to return to the facility

Ensure adequate emergency supplies

Keep up to date with the provisions you have on hand and if additional will need to be delivered. Know what particular items your facility and patients need a surplus of and how quickly they run through the items. If there becomes a shortage, have a backup plan of where and how timely you can retrieve the necessary items. Examples of items to have on hand:

• Water
• Food
• Batteries
• Medication
• Flashlights
• Bandages
• Oxygen

Create a plan for relocating residents and patients

Emergency situations are difficult for everyone. In particular, for those who are not in control or familiar with their surroundings. It is important to work with residents so they feel safe and cared for. Include in your emergency preparedness plan guidelines for how staff and volunteers should speak empathetically with residents, sharing details of their new location and continuing care.

3. CMS-Compliant Policies and Procedures

This portion of the CMS requirements will be highly tailored to your organization. In a call hosted by CMS going over the regulations as a whole, they stated the following about the policies and procedures requirements:

“Once an all-hazards approach has been conducted and a facility starts to put their emergency plan together, of course, this goes without saying, any type of facility has to develop policies and procedures to implement a plan of any kind. But it will be based on the risk assessment and emergency plan. And, again, policies and procedures will be required to be reviewed and updated on an annual basis. ”

This portion of the regulation is left pretty open-ended, allowing your organization to create a program that works best for you. It includes two main items:

• Policies and procedures must be developed and maintained—so ongoing policies are vital to staying compliant
• Policies and procedures must be reviewed and updated on an annual basis

The key to fulfilling this requirement is to fully develop and document your policies and procedures with a schedule for review, update, and maintenance built in to remain compliant. Use the flexibility of this requirement to build policies and procedures that work well for your organization and make ongoing compliance as easy as possible.

4. CMS-Compliant Training and Testing Program

To meet the training and testing portion of the new CMS guidelines, your facilities must complete the following two items:

• Initial training for new and existing staff in emergency preparedness policies and procedures
• Annual refresher training so that staff can demonstrate knowledge of emergency procedures

It seems that CMS left this section more open-ended intentionally. In the testing and training section of the final rule, CMS addresses some comments made regarding the lack of specificity in this area of the rule. They state that this allows for a more tailored approach that works best for the facility and the hazards that your organization faces. For some training scenarios, you may want to conduct drills; for others, you may want to run tabletop exercises.

This requirement aims to ensure the processes you’ve put in place work well and are fully compliant. If you’ve put solid systems in place for the other three portions of the emergency program, especially in the planning and communication areas, your training exercises and program testing will be greatly simplified. Consider the ongoing annual training requirements when developing the rest of your emergency program to stay compliant in the easiest, most efficient way.