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Updated Medicare Conditions of Participation: Emergency Preparedness

The Emergency Preparedness (EP) regulation for home health agencies is a separate rule; however, this  regulation is tied to the new Medicare Conditions of Participation (CoPs) for agencies as well. This means that agencies must remain compliant with requirements for emergency preparedness in order to be compliant with CoPs.

The Emergency Preparedness rule became effective November 15, 2016, with a required implementation date of November 15, 2017. Agencies should now have updated policies and procedures regarding their emergency preparedness plan, and should have trained their staff members on these updated policies and procedures to ensure compliance with the regulation.

When the surveyor visits the home health agency to assess for compliance with CoPs, he or she will be assessing the following:

  • Emergency Preparedness policies and procedures;
  • The agency’s EP plan is comprehensive in meeting the health, safety, and security needs of the staff and patient population during an emergency;
  • The EP plan addresses how the agency would coordinate and cooperate with other healthcare facilities, emergency preparedness officials, as well as the whole community during an emergency or disaster;
  • The EP plan is reviewed at least annually, and updated as needed;
  • The EP plan uses a facility-based and community-based, all-hazards approach specific to the location(s) of the agency;
  • The EP plan includes strategies to address emergency events identified by the risk assessment;
  • The agency’s plan to continue operations, including lines of authority, during an emergency;
  • The plans for each patient during a natural or man-made disaster;
  • Procedures for informing state and local emergency preparedness officials about the agency patients who need evacuation assistance during an emergency;
  • Procedures to follow up with staff who are on duty during an emergency;
  • Processes to follow up with patients to determine services that are needed during an emergency;
  • Policies and processes for reporting to appropriate officials’ information on staff members or patients that the agency has been unable to contact;
  • How medical documentation and patient information is preserved and confidentiality is maintained during emergency situations;
  • The agency’s communication plan, including current contact information for staff, patients, physicians, and emergency preparedness staff;
  • What primary and alternate means of communication have been chosen for use during an emergency; and
  • Training and testing of the agency’s emergency preparedness program, including review and any changes made due to these tests.

While this is not an all-inclusive list of requirements for emergency preparedness, agencies should be aware that the surveyor will conduct interviews with agency administration, as well as staff members while on site. Record review will take place to ensure that patients have been properly assessed and that their equipment information and contact information is up to date.

Emergency preparedness is an important part of ensuring patient safety. Because emergencies can occur at any time, the agency must be well versed and prepared to act accordingly. Patients should be taught how to prepare for emergencies, for example. Staff members may need several training opportunities to be able to locate or remember their roles during an emergency. If agencies are found to be non-compliant with emergency preparedness regulation, they may now be cited with a condition level deficiency and fines.

For more information regarding the emergency preparedness requirements, please view Axxess’ complimentary training video.

To review the emergency preparedness final rule, visit the Federal Register announcement and regulation.

Also see surveyor interpretive guidance regarding emergency preparedness and the CoPs final rule

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