If your healthcare facility is like others across the country, the clock is ticking. And, ticking fast. In less than 60 days – November 15, 2017 – you must comply with the Congress-approved CMS Emergency Preparedness Rule (Centers for Medicare and Medicaid, Federal regulations at 42 C.F.R. §§422.503 and 423.504). That is, if you want to continue receiving Medicare and Medicaid funding, or face other costly consequences. Read on to learn more about how the rule affects you, and some tips for achieving compliance in short order.
As a reminder, the ruling’s purpose is “to establish consistent emergency preparedness requirements for healthcare providers participating in Medicare and Medicaid, increase patient safety during emergencies, and establish a more coordinated response to natural and man-made disasters.” It covers a broad range of facilities, including hospitals, hospices, transplant centers, home health agencies, and Religious Nonmedical Health Care Institutions (RNHCIs). All must must meet the following four common and well-known industry best practice standards:
- Emergency plan: Based on a risk assessment, develop an emergency plan using an all-hazards approach focusing on capacities and capabilities that are critical to preparedness for a full spectrum of emergencies or disasters specific to the location of a provider or supplier.
- Policies and procedures: Develop and implement policies and procedures based on the plan and risk assessment.
- Communication plan: Develop and maintain a communication plan that complies with both Federal and State law. Patient care must be well-coordinated within the facility, across health care providers, and with State and local public health departments and emergency systems.
- Training and testing program: Develop and maintain training and testing programs, including initial and annual trainings, and conduct drills and exercises or participate in an actual incident that tests the plan.
Time is short.
An extension for CMS rule compliance does not appear likely. In fact, it seems even less so given the tragic death of eight long-term-care patients in a Hollywood, Florida facility following Hurricane Irma. This particular case, highly publicized by CNN, NPR and other news media, only validates the need for broader-reaching, all-hazards planning, as well as community-based emergency preparedness and response. It may also fuel the fire for Congress, which is fully expected to uphold the November 15, 2017 deadline for compliance.
Tip 1: Don’t delay any longer. If you haven’t done so already, commit your facility to compliance now. Review your current emergency operations plan (EOP) and supporting policies and procedures, and do whatever it takes to meet the basic requirements of the CMS ruling. Make every effort to ensure staff are knowledgeable of existing emergency procedures, and that they have been exercised within the last 12 months. Even baby steps may go a long way when submitting your program for review, or while undergoing a state-imposed survey. But, don’t expect leniency as there probably won’t be much of any.
Compliance is mandatory.
Adherence to the CMS rule is not an option; it is compulsory. Your facility must have standards that meet or exceed the four best practices identified for emergency planning; policies and procedures; communications; and training and testing. And, it should do so by November 15, 2017, when all emergency preparedness standards/programs are to be submitted to CMS for review. Take heed. Enforcement surveying will begin almost immediately, and there will be no exceptions as explained in CMS’ Survey & Certifications Group’s Frequently Asked Questions.
Tip 2: Expect some hiccups. Regardless of where your facility is in the process of adhering to the CMS rule, it will surely face some obstacles. Members of your emergency preparedness community may be slow to respond to your requests for participation; plan review and risk mitigation meetings may be delayed, or even cancelled; or, you could simply run out of time to fully test your emergency preparedness plan prior to the deadline for submission. Just push hard and push often so that your facility doesn’t face serious financial consequences, or even media backlash, as in the case of the Rehabilitation Center at Hollywood Hills, Florida post Irma. Sure, you might shake things up along the way, or even get under the skin of a few key stakeholders, but compliance with the rule will be well worth the effort in the long run.
Collaboration is key.
Developing and implementing an emergency preparedness plan that is compliant with the CMS rule may not be easy. But, it is doable, even with the deadline less than 60 days away. For starters, healthcare facilities, first responders, community leaders and others must get on the same page when it comes to emergency preparedness. They must engage in honest and open dialogue; document and share internal policies and procedures; work together to fill critical gaps, particularly in the area of communication; and put forth every effort to ensure their objectives, i.e., public safety, continuity of operations, hazard mitigation, etc., align. Just as important, they should allocate time and resources to revisit these goals on a regular basis – at least twice each year.
Tip 3: Know and grow your community. The CMS ruling does not include a clear definition for “community” involvement. It does, however, presume the inclusion of certain, logical entities, e.g., first responders, neighboring health care facilities, public health and others, that can support an integrated emergency response. If nothing else, start small to initially meet the CMS requirement and expand your community to include others over the coming weeks or months. Also, consider taking part in a healthcare coalition. CMS believes these non-profit organizations can “help to reduce the administrative burden on individual healthcare facilities and demonstrate the value of connecting into the broader medical response community, as well as the local health and emergency management agencies, during emergency preparedness planning and response activities.”
Help is available.
Understanding the CMS rule is one thing; complying is another. Fortunately, there are numerous resources available to help your facility develop and implement an all-hazards, community-based approach to emergency preparedness. These resources include documents for interpretive guidance from CMS.gov and ASPR/TRACIE; people, e.g., industry experts and consultants like those with BOLDplanning; and technology, namely online software that can make creating and updating such plans fast, easy and cost effective.
Tip 4: Loosen the purse strings. While operating budgets are always tight, your facility simply cannot afford to be non-compliant with the CMS emergency preparedness rule. The potential loss of Medicare and Medicaid reimbursements, which now accounts for as much as 30-50% of the total revenue for hospitals and healthcare providers across the U.S., may prove too much for the bottom line. Your facility’s reputation could become tarnished, or you might face serious legal repercussions if staff and patient safety measures are not upheld. Make every effort to identify, reallocate, or secure funds to achieve better emergency preparedness. The benefits far outweigh the costs, and you will see an immediate return on investment should a natural disaster or other hazard occur.
With less than 60 days to go, the countdown to CMS compliance is on and BOLDplanning can help. Learn more about the rule and BOLDplanning by downloading the company’s latest White Paper, CMS Emergency Preparedness Final Rule: 10 Reasons Why You Need Online Planning Software for Better Compliance.