65th annual ahca/ncal convention &...

65th Annual AHCA/NCAL Convention & Expo

Federal Town Hall:

“Enhancing Provider Navigation of Federal Programs, Assistance, and Waivers Prior to, During, and After a

Disaster “

United States Department of

Health & Human Services Office of the Assistant Secretary for Preparedness and Response

Disaster Preparedness: A Multi-Faceted Approach to

At-Risk Individual, Caregiver and Facility Emergency Planning

Thursday, April 17, 2014 AHCA/NCAL Annual Convention & Expo

Cheryl Levine, Ph.D.

Team Lead for At-Risk Individuals Division for At-Risk Individuals, Behavioral Health,

and Community Resilience (ABC) Office of the Assistant Secretary for Preparedness and Response (ASPR)

U.S. Department of Health and Human Services (HHS)

ASPR: Resilient People. Healthy Communities. A Nation Prepared.

Basic Preparedness

Three easy steps toward emergency preparedness are: 1.Build a Kit 2.Make a Plan 3.Be Informed

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Planning for the whole community requires additional consideration • Children • Pregnant Women • Older Americans • Others

Whole Community


Before, during and after an incident, at-risk individuals are those who may have additional needs.

Access and Functional Needs


• Whole Community • Social Capital • Health Promotion • Social Connectedness

Community Health Resilience


HHS, Administration on Aging (AoA), Older Americans Act (OAA) waiver • Limited funds to State Units on Aging and OAA funded tribal

organizations as a reimbursement for additional expenses incurred following a Presidentially-declared disaster to assist older persons and their caregivers

• Outreach, case management, counseling, extra meals and food supplies, in-home assistance and clean-up, emergency transportation and medicines, staff overtime and other gap-filling or supportive services not available from other resources to help older persons and their caregivers through an emergency.

Older Americans Act

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US Department of Health and Human Services (HHS) Office of the Assistant Secretary for Preparedness and Response (ASPR)

Administration for Community Living (ACL)

http://www.phe.gov/Preparedness/planning/abc/Pages/caregiver-webinar.aspx

Disaster Preparedness Planning Resources for Individuals, Caregivers, and Facilities





• HHS Administration on Aging • Just in Case: Emergency Readiness for Older Adults and Caregivers: This fact

sheet provides step-by-step information on how older adults should prepare for a disaster/emergency. It includes helpful checklists, contact lists, and a medication list that can be filled in.

• http://www.aoa.gov/AoARoot/AoA_Programs/HCLTC/Caregiver/docs/Just_in_Case030706_links.pdf

• http://www.aoa.gov/AoARoot/AoA_Programs/HCLTC/Caregiver/docs/SpanishDisasterReadiness.pdf

• Disaster Preparedness: Home and Community-Based Services for People with Dementia and Their Caregivers: This toolkit outlines actions states can take to empower caregivers to make informed decisions about the special needs of people with dementia at a time of emergency or disaster.

• National Family Caregiver Support Program: This guide outlines emergency readiness for older adults and caregivers.

• Resources for Individuals, Families and Caregivers: This toolkit provides resources that will assist in developing priorities, best practices, and best actions in preparing for, and responding to, an emergency or disaster.

Caregiver Preparedness Resources

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http://www.aoa.gov/AoARoot/AoA_Programs/HCLTC/Caregiver/docs/Just_in_Case030706_links.pdf

http://www.aoa.gov/AoARoot/AoA_Programs/HCLTC/Caregiver/docs/Just_in_Case030706_links.pdf

http://www.aoa.gov/AoARoot/AoA_Programs/HCLTC/Caregiver/docs/SpanishDisasterReadiness.pdf

http://www.aoa.gov/AoARoot/AoA_Programs/HCLTC/Caregiver/docs/SpanishDisasterReadiness.pdf

http://www.aoa.gov/aoaroot/Preparedness/Resources_Network/pdf/Toolkit_2_Disaster_Preparedness.pdf

http://www.aoa.gov/aoaroot/Preparedness/Resources_Network/pdf/Toolkit_2_Disaster_Preparedness.pdf

http://www.aoa.gov/aoaroot/AoA_Programs/HCLTC/Caregiver/docs/Just_in_Case030706_links.pdf

http://www.aoa.gov/aoaroot/Preparedness/Resources_Individuals/index.aspx


ASPR Resources (PHE.GOV/ABC)

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• CDC Identifying Vulnerable Older Adults and Legal Options for Increasing their Protection During All-Hazards Emergencies: A Cross-Sector Guide for States and Communities

• CDC Emergency Preparedness for Older Adults Legal Information

• ASPR Healthcare Preparedness Capabilities-National Guidance for Healthcare System Preparedness

• National Health Security Strategy Implementation Plan (2012)

• CDC Public Health Preparedness Capabilities-National Standards for State and Local Planning

Emergency Preparedness Guidelines

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http://www.phe.gov/Preparedness/planning/hpp/reports/Documents/capabilities.pdf


• CMS Emergency Preparedness Checklists/FAQs: • CMS Emergency Preparedness Checklist--Recommended Tool

for Effective Health Care Facility Planning http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Downloads/SandC_EPChecklist_PersonsMedicalNeedsLivingatHome.pdf

• CMS Emergency Preparedness Checklist--Recommended Tool for Persons in LTC Facilities & Their Family Members, Friends, Personal Caregivers, Guardians & Long-Term Care Ombudsmen http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Downloads/SandC_EPChecklist_Provider.pdf

• CMS Survey and Certification All Hazards FAQs http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Downloads/AllHazardsFAQs.pdf

Emergency Preparedness CMS Checklists

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http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Downloads/SandC_EPChecklist_PersonsMedicalNeedsLivingatHome.pdf



http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Downloads/SandC_EPChecklist_Provider.pdf



http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Downloads/AllHazardsFAQs.pdf




• Emergency Power Assessment Tools and Resources • U.S. Army Corps of Engineers (USACE) Emergency Power Facility

Assessment Tool (EPFAT) and Informational Videos http://epfat.swf.usace.army.mil/

• FAQs:http://eportal.usace.army.mil/sites/ENGLink/EmergencyPower/Shared%20Documents/Emergency%20Power%20Facility%20Assessment%20Tool%20Fact%20Sheet%2030%20May%202012.pdf

• YouTube: http://www.youtube.com/watch?v=kq2CaSSRYV8

• ASPR Planning for Power Outages: A Guide for Hospitals and Healthcare Facilities http://www.phe.gov/Preparedness/planning/cip/Documents/healthcare-energy.pdf

Facility Emergency Power Resources

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http://epfat.swf.usace.army.mil/

http://eportal.usace.army.mil/sites/ENGLink/EmergencyPower/Shared%20Documents/Emergency%20Power%20Facility%20Assessment%20Tool%20Fact%20Sheet%2030%20May%202012.pdf



http://www.youtube.com/watch?v=kq2CaSSRYV8

http://www.phe.gov/Preparedness/planning/cip/Documents/healthcare-energy.pdf

http://www.phe.gov/Preparedness/planning/cip/Documents/healthcare-energy.pdf

Scott Dugas Chief, Hospital Preparedness Program Branch Division of National Healthcare Preparedness

Programs

Hospital Preparedness Program (HPP)

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Hospital Preparedness Program (HPP): Focus on the Healthcare System

The Hospital Preparedness Program is not just focused on hospitals – it is the link between public health, hospitals, emergency management, and other key federal, state, and local health partners. HPP strives to develop a robust, integrated federal, state, and local disaster healthcare system that is prepared and ready to respond to any emergency event.

HPP By the Numbers

Annual 1-year appropriation

$255 million for FY 2014, a 30 percent drop from FY 2013 62 awardees – states, localities, territories and freely associated states – who support healthcare coalitions (HPP does not directly fund hospitals)

16,000 healthcare coalition members nationwide

Cooperative Agreement Funding Allocations Over Time:

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Evolution from “Stuff” to Systems

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What is a Healthcare Coalition? A formal collaboration among healthcare organizations and public and private sector partners that is organized to prepare for, respond to, and recover from an emergency, mass casualty or catastrophic health event

HPP Healthcare Coalitions: The Cornerstone of Healthcare Preparedness

• Comprehensive Membership: Acute care hospitals, EMS, specialty and primary care providers, long term care facilities, behavioral health, public agencies, and private organizations

• Regional Presence: Developed within states/territories to

cover geographic area

• Operationalizes Preparedness Capabilities: Through plans, exercises, trainings, response, and after action reports

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HPP Healthcare Coalition Members: ~16,000 nationwide

Long Term Care 15%

In-patient hospitals 29%

EMS 10%

Public Health 7%

Emergency Management 6%

Community Health Centers

6%

Other 27%

National Target is an Additional 50,000 Healthcare Coalition Members by June 2017

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West, TX Explosion 2013 • 300 patients treated in hospitals, (288 in 3

facilities) • 128 nursing home residents evacuated

without identification or medical records • Local coalition was able to synchronize

medical surge beyond need (cancelled procedures, deployed Ambuses, moved patients within facilities)

HPP is Critical for Preparedness and Response: West, TX Explosion

“The medical and public health response to the West, Texas Fertilizer Plant Explosion is a true exemplification of Hospital Preparedness Program (HPP) success. The medical surge planning and use of deployable assets were successfully tested in a real world disaster and proved to be effective and essential.” Bruce Clements, MPH Director Community Preparedness Section Texas Department of State Health Services

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Communities of Interest (COI) Sharepoint Site

• Communities of Interest (COI) includes all of the interested parties involved in crisis standards of care (CSC) and allocation of scarce resource (ASR) planning.

• Platform to disseminate information, post relevant plans, articles and documents, and to share promising practices, ideas, and lessons learned:

Sample crisis standards of care (CSC) plans as part of a

resource library and document repository Allocation of scarce resources, and immediate bed

availability planning documents

• URL: www.phe.gov/COI

Contact the Hospital Preparedness Program

Scott Dugas, HPP Branch Chief 202-245-0732 Email: [email protected]

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mailto:[email protected]



Glenn Blanchette

Regional Administrator HHS/ASPR National Capital Region

Regional and International Coordination Division Office of Emergency Management

Office of the Assistant Secretary for Preparedness and Response U.S. Department of Health and Human Services

URL: www.phe.gov

http://www.phe.gov/

ASPR: Resilient People. Healthy Communities. A Nation Prepared. 24

Objective

• Describe federal health and medical disaster support coordinated through the Office of the Assistant Secretary for Preparedness & Response (ASPR) to assist federal, state, tribal and territorial governments in a public health emergency or federally declared disaster.


National Response Framework (NRF)

ESF1 - Transportation ESF2 - Communications ESF3 - Public Works and Engineering ESF4 - Firefighting ESF5 - Emergency Management ESF6 - Mass Care, Emergency Assistance, Housing and Human Services ESF7 - Logistics Management and Resource Support ESF8 - Public Health and Medical Services ESF9 - Search and Rescue ESF10 - Oil and Hazardous Materials Response ESF11 - Agriculture and Natural Resources ESF12 - Energy ESF13 - Public Safety and Security ESF14 - Long-Term Community Recovery ESF15 - External Affairs


HHS / ESF8 Core Functional Areas

• Assessment of public health/medical needs

• Public health surveillance • Medical care personnel • Medical equipment and supplies • Patient movement • Hospital care • Outpatient services • Victim decontamination • Safety and security of human

drugs, biologics, medical devices, veterinary drugs, etc.

• Blood products and services • Food safety and security

• Agriculture feed safety and security • Worker health and safety • All hazard consultation and technical

assistance and support • Mental health and substance abuse

care • Public health and medical information • Vector control • Potable water/wastewater and solid

waste disposal, and other environmental health issues

• Victim identification/mortuary services • Veterinary services • Medical materiel, personnel, and

technical assistance


HHS Department

HHS Operating Divisions

• Administration for Children and Families (ACF) • Administration for Community Living (ACL) • Agency for Healthcare Research and Quality (AHRQ) • Agency for Toxic Substances and Disease Registry (ATSDR) • Centers for Disease Control and Prevention (CDC) • Centers for Medicare and Medicaid (CMS) • Food and Drug Administration (FDA) • Health Resources and Services Administration (HRSA) • Indian Health Service (IHS) • National Institutes of Health (NIH) • Substance Abuse and Mental Health Services Admin

(SAMSHA)


HHS Response Authorities

• Pandemic All-Hazards Preparedness Reauthorization Act of 2013 (PAHPRA)

• Public Health Service Act • Social Security Act • Federal Food, Drug, and Cosmetic Act • Stafford Act: The Robert T. Stafford

Disaster Relief and Emergency Assistance Act


The HHS Secretary shall: • Lead all Federal public health and medical response to public health

emergencies and incidents covered by the National Response Framework (NRF), or any successor plan

The Assistant Secretary for Preparedness and Response (ASPR) shall: • Have the lead responsibility within HHS for emergency preparedness and

response policy coordination and strategic direction

• Authority over and responsibility for: • National Disaster Medical System (NDMS) • Hospital Preparedness Cooperative Agreement (HPP) • Biomedical Advanced Research and Development (BARDA) • Medical Reserve Corps (MRC) • Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP)

• Responsibilities and authorities of the Secretary with respect to the coordination of: • Public Health Emergency Preparedness Cooperative Agreement Program (PHEP) • Strategic National Stockpile (SNS) • Cities Readiness Initiative (CRI)

PAHPA Reauthorization of 2013


HHS Response Activation

HHS is the lead coordinating agency for federal public health and medical response when: • The HHS Secretary, using her authorities, declares

a Public Health Emergency (PHE) • Federal assistance is requested by State, Tribal,

Territorial or local authorities • A Federal department or agency, acting under its

own authority, requests HHS assistance (i.e. FEMA via the Stafford Act)


• ASPR: Dr. Nicole Lurie, heads the ASPR Staff Division in the Office of the Secretary, and serves as the Secretary’s principal advisor on issues related to bioterrorism, and leads a collaborative approach to the department’s preparedness, response, and recovery portfolio

• ASPR’s Mission: Lead the country in preparing for, responding to, and recovering from the adverse health effects of emergencies and disasters by supporting our communities’ ability to withstand adversity, strengthening our health and response systems, and enhancing national health security

• ASPR’s Strategic Goals Include:

• Promote resilient communities by fostering a nation able to withstand and recover from public health emergencies.

• Improve health outcomes from disasters by strengthening the ability of our Nation's health care system to effectively respond and recover

• Strengthen leadership and capabilities within public health and medical emergency management to include prevention, preparedness, mitigation, response, and recovery

• Additional information can be found at HHS’s Public Health Emergency (PHE)

webpage: www.phe.gov

Office of the Assistant Secretary for Preparedness and Response Overview

Nicole Lurie, M.D., M.S.P.H.

http://www.phe.gov/


ASPR Office of Emergency Management (OEM) • Mr. Don Boyce, OEM Director

• OEM Divisions: • Regional and International Coordination (RICD)

• Regions / Regional Emergency Coordinators (REC)

• Healthcare Preparedness Program (HPP) • National Disaster Medical System (NDMS) • Operations • Tactical Programs • Planning • Fusion • Logistics • Resilience and Infrastructure Coordination • Recovery

ASPR’s Office of Emergency Management


• Office of Emergency Management (OEM) • Leads HHS preparedness planning, response, and recovery activities • Directs and manages the HHS’ Secretary’s Operation Center (SOC)

• Emergency Management Group (EMG) • Consists of HHS Operating Divisions and ESF8 partner agency

representatives • Provides strategic guidance and operational support to field operations

ASPR Headquarters Response Coordination

• Secretary’s Operations Center (SOC) • Staffed 24/7 to maintain national situational

awareness • Facility which supports OEM and EMG

operations


HHS Regions

NCR

http://www.phe.gov/Preparedness/responders/rec/Pages/contacts.aspx


Regional Emergency Coordinators (RECs)

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ASPR’s regional representatives for:

• Preparedness • Lead for both HHS and ESF8 disaster preparedness

planning

• Response • Federal Health Official (FHO)

• Lead for HHS and ESF8 field operations • Liaison Officers (Federal, State, local) • Commander, HHS Incident Response Coordination

Team (IRCT) • Management and support of HHS field assets

• Recovery • Support recovery operations


Res

pons

e S

uppo

rt

Federal and EMAC Response

State Response

Increasing magnitude and severity

Local, County and Regional Response

“All Disasters Are Local”

Low Medium High Catastrophic


Response Operations


Spectrum of Federal Medical Resources

NDMS Medical Teams (DMAT, NVRT, Specialty Medical Teams)

Medical Reserve Corps

VA and DOD

NDMS Hospitals

NDMS DMORT

USPHS APHT

USPHS MHT

USPHS RDF

Basic First Aid

Outpatient Care

Hospital Inpatient Care

Nursing Home Care

Special Medical Needs Care

Fatalities Management

Pre-Hospital and Emergency Room Care

Food / Water Safety

Drug / Blood Safety

Behavioral Health

Health Surveillance

ICU/ Trauma Critical Care

Medical Logistical Resources – durable equipment, pharmaceuticals and supplies

Pet / animal care


Requests for HHS/ESF8 assistance are coordinated through the FHO-RECs

HHS Assistance (No Presidential Declaration)

• Local ’ State (Health Dept. / EMA / Governor) ’ HHS/ASPR • ASPR Request Form or formal letter • Cost share TBD

HHS/ESF8 Assistance (Stafford Act/Presidential Declaration)

• Local ’ State EMA (SCO) ’ FEMA (FCO) ’ ESF-8/HHS • Resource Request Form (RRF) … old Action Request Form (ARF) • Cost share (75% Federal / 25% State)

Requesting Assistance / Support


• HHS offers a wide spectrum of assistance: • Regulatory waivers • Technical assistance • Response assets

• Health and medical personnel • Equipment and supplies

• ASPR “The One Stop Shop” • HHS and Federal ESF8

• Preparedness, and response • Federal Heath and Social Service (HSS) Recovery Support

Function (RSF) • Recovery

• RECs are your primary contact for HHS/ESF8 for preparedness and response activities

Take Home Message

James J. Merrill

Life Safety Code Engineer, Division of Nursing Homes Centers for Medicare & Medicaid Services

U.S. Department of Health and Human Services

Centers for Medicare & Medicaid Services:

An Overview of CMS Waivers and Roles

During Emergency Response and Recovery

CMS & Disaster Response

• When disasters – man-made or natural – strike, CMS has a role to play in response & recovery, through: – 1135 waivers – Requirements/Conditions of Participation

flexibilities not requiring 1135 waivers – Requiring providers/suppliers to be prepared – QIO Assistance – Exemptions from reporting penalties

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Frequently Asked Question (FAQ) CMS Websites Addressing Emergency Response

CMS has developed a number of FAQ to address many of the issues providers and suppliers face when responding to disaster. Some of the topics addressed include:

• Requesting an 1135 waiver

• Flexibilities under an 1135 waiver

• Flexibilities that exist without an 1135 waiver

• Establishing alternative care sites

• EMTALA flexibilities with an 1135 waiver

The link below can be used to connect to these FAQ:

https://www.cms.gov/About-CMS/Agency-Information/H1N1/

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1135 Waivers

• Permitted under Section 1135 of the Social Security Act

• Purpose: – Ensure sufficient health care items and services are

available during a disaster to meet the needs of Medicare, Medicaid and CHIP beneficiaries;

– Health care providers that provide services in good faith during a disaster can be paid, and not subjected to sanctions for noncompliance, absent any fraud or abuse 44

High Threshold for 1135 Waivers

• Presidential Declaration – National Emergencies Act; OR

– Stafford Act

• AND

• Secretarial Declaration of a Public Health Emergency under Section 319 of PHS Act

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1135 Waiver Scope

• Section 1135 authorizes the Secretary to waive or modify certain Medicare, Medicaid or CHIP requirements in certain kinds of emergencies

– Generally, coverage rules, payment rules, & rules

applicable to beneficiaries may NOT be waived or modified

• Applies to Federal Requirements only, not state

licensure or other State requirements

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Examples of 1135 Waiver Authorities

• Requirements/Conditions of Participation

• Licensure for Practitioners to provide services in affected state(s)

• Emergency Medical Treatment and Labor Act (EMTALA), but only for – Sending folks for screening to off-campus sites

– Transferring individuals with unstable emergency medical conditions

– Limited time

• Stark Self-Referral Sanctions

• Medicare Advantage out of network providers

• HIPAA

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1135 Waiver Duration

• Waiver ends no later than the termination of the emergency period, or 60 days from the waiver date, unless the Secretary extends for added periods up to 60 days, up to the end of the emergency period.

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1135 Waiver Review Process

1. Is the request for a waiver within defined emergency area? 2. Is there an actual need for the waiver? 3. What is the expected duration of the need for a waiver to address the emergency? 4. Can the issues be resolved within current regulations? 5. Will the regulatory relief requested address the stated need? 6. Should CMS consider individual or blanket waivers?

. an actual need? • Will Regulatory relief requested actually address stated need?

• Can this be resolved within current regulations? • Should we consider individual or blanket waiver? • What is the expected duration?

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Waiver Review Inputs

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Expectations of Waived Providers

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Examples of Actual Waivers

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Actual Waivers

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Survey/Enforcement Activities

• Survey activities may be impacted by a declared public health emergency

• Enforcement actions may be deferred for facilities in an emergency area, including denial of payment for new admissions (DPNA)

• Case by Case basis review and recommendation by SA

• Civil Money Penalties(CMP) may be deferred or suspended in affected area

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Flexibilities

• 3-Day Hospital Stay • CMS will Temporarily provide SNF benefits in the absence of

the 3-day prior hospital stay for SNF residents • Medicare beneficiary

– Was evacuated from a nursing home in emergency area – Was discharged from a hospital in order to provide care to more seriously ill

patients; or – Needs SNF care as a result of the emergency, regardless of whether that

individual was in a hospital or SNF prior to the disaster.

• Provider must document in the medical record both the medical need and related to the public health emergency and aftermath

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Requirements/CoP Flexibilities – No 1135 Waiver Needed

• Life Safety Code waivers are always permitted – With or without an 1135 waiver

• To meet community needs, CMS can make extended LSC waivers available after 1135 waivers expire, or where no 1135 waivers issued – E.g. temporary facilities during an emergency

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Current Preparedness Regulations

• Even without specific wording that address disaster response, the long term care Requirements/Conditions of Participation apply at all times (unless a specific 1135 or LSC waiver is in place).

• Therefore, long term care facilities are currently expected to anticipate their likely emergencies and plan how they will continue to care for their residents (or, when needed, transfer them) in a manner that complies with the long term care Requirements/CoP, even during a disaster!

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U.S. Small Business Administration Office of Disaster Assistance

Federal Disaster Loans for Homeowners, Renters and Businesses of All Sizes

Sequence of Delivery

ODA Mission To provide affordable, timely, and accessible financial assistance to businesses, homeowners and renters following a declared disaster.


Major Loan Activity in Past 20 Years ($ billions)

Historical Lending Since 1953, SBA has approved over $53 billion to nearly 2,000 homeowners, renters and businesses following America’s worst natural and manmade disasters.


Home and Personal Property Disaster Loans


Business Physical Disaster Loans


Economic Injury Disaster Loans


Three Step Process

• Apply: 1) online; 2) in-person at a disaster center; or 3) by mail. • Apply online at the SBA’s secure website https://disasterloan.sba.gov/ela. • As a business of any size, you may borrow up to $2 million for physical

damages. • As a small business, small agricultural cooperative, small business

engaged in aquaculture, or private nonprofit organization you may borrow up to $2 million for Economic Injury Disaster Loan (EIDL).

• As a small business you can apply for maximum business loan (physical and EIDL) of $2 million.

• As a homeowner you may borrow up to $200,000 to repair/replace your disaster damaged primary residence.

• As a homeowner or renter, you may borrow up to $40,000 to replace damaged personal property.

STEP 1: Apply for Loan


https://disasterloan.sba.gov/ela

Three Step Process STEP 2:

Property Verified and

Loan Processing Decision Made

• SBA reviews your credit before conducting an onsite inspection to verify your losses.

• An SBA verifier inspects your damaged property to estimate your total physical losses.

• The loan officer will determine your eligibility during processing after reviewing any insurance or other recoveries. SBA can make a loan while insurance recovery is pending.

• A loan officer works with you to provide all the necessary information needed to reach a loan determination. Our goal is to arrive at a decision on your application in 2-3 weeks.

• The loan officer will contact you to discuss the loan decision and next steps. You will also be advised in writing of all loan decisions.


Three Step Process

• SBA will prepare and send your Loan Closing Documents to you for your signature. • Once we receive your signed Loan Closing Documents, an initial disbursement will be

made to you within 5 days: o Physical damage:

$25,000 (Presidential declarations) $14,000 (Agency declarations)

o Economic injury (working capital): $25,000 (all declarations)

• A case manager will be assigned to work with you to help you meet all loan conditions and schedule subsequent disbursements until you receive the full loan amount.

• Your loan may be adjusted after closing due to your changing circumstances, such as increasing the loan for unexpected repair costs or reducing the loan due to additional insurance proceeds.

STEP 3: Loan Closed and Funds

Disbursed


For More Information


U. S. Small Business Administration Disaster Assistance Customer Service Center

(800) 659-2955 TTY (800) 877-8339

Email: [email protected] or

Visit our Web site at: www.sba.gov/disaster


http://www.sba.gov/disaster

Shoshana Resnick Executive Communications Officer – Public Assistance

U.S. Department of Homeland Security’s Federal Emergency Management Agency

FEMA’s Public Assistance Program 65th Annual AHCA/NCAL Convention


Public Assistance Grant Program

Mission: To provide supplemental financial assistance to state, local and tribal governments, and certain private nonprofit organizations for response and recovery activities required as the result of a declared disaster. Funding is cost shared at a federal share of no less than 75% of eligible costs.


Doctrine: The Public Assistance Program is based on statutes, regulations and policies. The Robert T. Stafford Disaster Relief and Emergency Assistance Act (Stafford Act) is the underlying document that authorizes the program.

• Regulations published in Title 44 of the Code of Federal Regulations (44 CFR) Part 206 implement the statute.

• Policies are written to apply the statute and regulations to specific situations (9500 Series Policy Publications).

Public Assistance Grant Program


PDA Governor’s

Request Declaration

Applicants’ Briefing

Submission of Request

Kick-off Meeting

Formulation of Projects

Project Review

Grantee

Approval

Funding Subgrantee


Applicant

Facility

Work

Cost

Eligibility Structure


• State Government

• Native American Tribes or Tribal Organizations

• U.S. Territories

• County Government

• City Government

• Certain Private Nonprofit Organizations

Eligible Applicants


Applicants should:

• Attend a state-sponsored Applicants’ Briefing to receive information about the Public Assistance Program and state requirements.

• Complete and submit to the state a Request for Public Assistance (RPA) form. Applicants may submit the RPAs at the Applicants’ Briefing or submit them to the State within 30 days following the designation of the area in which the damage is located.

The Application Process


AHCA/NACL AHCA/NACL

PA Policies applicable to eligible healthcare stakeholders


American Samoa Territory of Aging (ASTOA) view from Field

American Samoa Commerce Bank in Front of ASTOA


American Samoa Territory of Aging (ASTOA) view across the street

View across from ASTOA. Red truck in side (top left) of Community Center and boat inside bldg.


9523.3 Provision of Temporary Relocation Facilities (12/14/10) Provides guidance on determining eligibility for and duration of a temporary facility under the PA Program. Services provided at public and private nonprofit (PNP) facilities may be disrupted to the extent that they cannot continue unless they are temporarily relocated to another facility. Updates the facilities that are eligible for temporary relocation to include PNP facilities that provide health and safety services of a governmental nature. Ancillary facilities may also be eligible, such as administration buildings and hospital laundry facilities.




9525.2 Donated Resources (2/26/14) Donated resources used on eligible work that is essential to meeting immediate threats to life and property resulting from a major disaster may be credited toward the non-Federal share of grant costs under the PA program. The change allows the value of mass care and sheltering activities provided by a voluntary agency to be applied to the non-Federal share as a donated resource even when those activities are part of the volunteer agency’s mission.



9580.104 Fact Sheet: Public Assistance for Ambulance Services (1/2/09) Eligible ambulance service provider costs may include the costs of activating ambulance contracts and staging of ambulances (contract or publicly owned) prior to the impact of an incident, such as landfall of a hurricane, typhoon, or tropical storm. Contracts for staging ambulance services must be part of the state or regional evacuation plan. The costs of staging ambulances are eligible even if the incident does not directly impact the staging area, provided the President declares an emergency or major disaster.



9525.7 Labor Costs - Emergency Work (11/16/06) Provides guidance on the eligibility of labor costs for permanent, temporary, and contract employees who perform emergency work. The cost of straight-time salaries and benefits of an applicant’s permanently employed personnel is not eligible in calculating the cost of eligible emergency work. Straight time and overtime will be determined in accordance with the applicant’s pre-disaster policies and all costs including premium pay must be reasonable and equitable for the type of work being performed. Guidance is given for fixed-term employees, seasonal employees, temporary hires, and backfill employees.



9580.7 Fact Sheet Host-State Evacuation and Sheltering Frequently Asked Questions (7/23/10) Answers 50 of the most frequent questions about host-state evacuation and sheltering, including mutual aid, straight-time salaries and benefits of a host-State’s permanent employees, National Guard costs, American Red Cross (ARC) or other Non-Governmental Organizations (NGOs) costs, nursing home or assisted living-related services, and emergency medical treatment in accordance with policy. Also answers procedural and reimbursement questions.



9525.7 Labor Costs - Emergency Work (11/16/06) Provides guidance on the eligibility of labor costs for permanent, temporary, and contract employees who perform emergency work. The cost of straight-time salaries and benefits of an applicant’s permanently employed personnel is not eligible in calculating the cost of eligible emergency work. Straight time and overtime will be determined in accordance with the applicant’s pre-disaster policies and all costs including premium pay must be reasonable and equitable for the type of work being performed. Guidance is given for fixed-term employees, seasonal employees, temporary hires, and backfill employees.

Shoshana Resnick Executive Communications Officer – Public Assistance

Federal Emergency Management Agency [email protected]


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Office of Fair Housing and Equal Opportunity

OVERVIEW OF

THE OFFICE OF HEALTHCARE PROGRAMS

FHA MORTGAGE INSURANCE FOR RESIDENTIAL CARE FACILITIES

(AND HOSPITALS) OCTOBER 6, 2014

86

Healthcare Program Definitions • 232 - Section 232 of the NHA gives FHA the authority to insure

mortgages for nursing homes, assisted living, and other long-term care residential facilities

• 223 (f) - Section 223 (f) of the NHA Act gives FHA the authority to insure mortgages for 100 % refinancing loans pursuant to 242 and 232

• 223 (a)(7) - Section 223 (a)(7) of the NHA Act gives FHA the authority to insure refinanced mortgages for HUD portfolio facilities.

• 241 - Section 241 of the NHA gives FHA the authority to insure supplemental loan mortgages for HUD portfolio facilities.

• 242 - Section 242 of the National Housing Act (NHA) gives HUD/FHA the authority to insure mortgages for acute care hospitals.

87

Overview • Office of Healthcare Programs (OHP) consists of: Office of Residential Care Facilities (ORCF) Office of Hospital Facilities (OHF) Office of Architecture and Engineering (support

office)

• OHP’s mortgage insurance programs enable affordable financing of healthcare facilities Section 232 Mortgage Insurance for Residential

Care Facilities Section 242 Mortgage Insurance for Hospitals

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Organization of the Office of Healthcare Programs HUD Headquarters

Federal Housing Administration

Deputy Assistant Secretary

Roger Miller

Office of Hospital Facilities (Section 242)

Geoffrey Papsco

Policy and Planning Advisor John Whitehead

Financial Analysts Account Executives

Staff Assistants

Advisory Council 3 Consultants

(Part-time)

Functions include policy/process analysis, policy/regulations/ guidance development, reports and briefings

Functions include strategic advice, industry analysis, intervention with troubled hospitals

Functions include portfolio management, underwriting,

client assistance, default

prevention

Office of Architecture and Engineering Teresa Bilyk

Architects Engineers Secretary

Functions include approval of plans, specifications, and contracts and monitoring of construction projects

Healthcare Systems Advisor Vacant

Functions include championing Lean, continuous improvement, credit committees, strategic advice

Office of Residential Care Facilities (Section 232)

Roger Lewis

Project Managers Financial Analysts

Account Executives Construction Analysts

Appraisers Program Analysts

Associate Deputy Assistant Secretary

Roger Lukoff

Special Assistants Ivy Jackson

Glorianna Peng

Functions include IG/GAO audit resolution, management plan reporting, reports and briefings, data systems, communications

Budget, Contracts, and Administrative Support

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What We Do • Enable the affordable financing of needed healthcare

facilities through the provision of mortgage insurance • Improve access to quality healthcare nationwide at no

cost to the taxpayer • Reduce cost of care and increase accessibility

Allow borrowers to achieve higher credit ratings • Strengthen communities - healthcare facilities are

economic engines Healthcare facilities employ millions of Americans and

support trillions in economic activity

90

Our Office • An office of 151

professionals with expertise in and a single focus on the financing and operations of healthcare facilities.

Elizabeth Seton Pediatric Center Yonkers, NY

Citrus Health and Rehabilitation Skilled Nursing Facility Inverness, FL

91

Qualifications of OHP Program Staff • Former Health Care Executives • Former Business (Lending, Finance, etc.) Executives • Professional Society Fellows • Former State Finance Authority Executives • Majority of Staff Possess Graduate Degrees, including:

PhDs Juris Doctors MBAs Masters

• Certified Public Accountants • Registered Architects • Professional Engineers • Registered/Licensed Nurses • State-Certified Appraisers • Licensed Realtors • Former Office of Multifamily Staff Members

92

Locations

Stoddard Baptist Home Washington, DC

• Office of Residential Care Facilities (Section 232) Headquarters and out-

stationed to 23 field locations • Office of Architecture and

Engineering New York Field Office, with

some out-stationed staff members

• Office of Hospital Facilities (Section 242) Headquarters and New York

Field Office, with some out-stationed staff members

93

History of FHA’s Office of Healthcare Programs

• Section 232 of the National Housing Act was established by Congress in 1959 To support the critical care needs

of a vulnerable aging population in residential care facilities across the country

Ashford Place Shelbyville, IN

SECTION 232

95

Office of Residential Care Facilities • Comprised of 3 divisions: Production Division

functions include processing Section 232 applications and loan closings

Asset Management and Lender Relations Division functions include loan monitoring,

lender assistance, and default prevention

Policy and Risk Analysis Division functions include policy

development, risk management, and communications

Florence Park, Care Center Florence, KY

97

Section 232 Program • FHA provides residential care facility

mortgage insurance nationwide: Nursing Homes Assisted Living Facilities Board and Care Homes

• Over 2,900 loans presently insured under this program Located in 49 states, the District of Columbia and

the Virgin Islands. • Over $20.8 billion in insured mortgages

98

232 Residential Care Portfolio

ARCHITECTURE & ENGINEERING

100

• The Office of Architecture and Engineering (OAE): Supports the Section 232 and Section 242

mortgage insurance programs Functions include: Review and approval of architecture and

engineering plans, specifications, and contracts through the application process Monitoring of hospital construction projects Performing environmental (HUD-4128) reviews

for 242 and 232 program applications

Architecture and Engineering

101

Environmental Responsibilities • OAE continues to perform the environmental

reviews for proposed FHA projects • OAE is continuing to work closely with the

FHA-232 program to help do HUD 4128 environmental assessments and reviews of property surveys to expedite the queue

• OAE continues to keep abreast of latest developments in environmental matters by training staff

102

OAE & Natural Disasters • OAE supports portfolio healthcare facilities

before and after the occurrence of natural disasters

• OAE is currently monitoring construction of a projects that were severely damaged due to various disasters such as Hurricane Katrina, Sandy, etc.

103

OAE & Natural Disasters • After Hurricane Sandy, OAE

inspected several facilities to verify its physical condition. Utilizing floodplain requirements in its original design saved the hospital from incurring millions of dollars in damages.

• Moore Medical Center-Moore, Oklahoma-sustained damage due to Category 5 Tornado

104

• Complete guidance found on website • First step is to find FHA-Approved Lender • Lender guides applicant through process • Lender submits application for applicant • HUD will review and make determination • HUD notifies Lender who then finalizes details

with applicant

Section 232 Process Summary

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• HUDS’s Office of Residential Care Facilities (ORCF) Section 232

http://portal.hud.gov/hudportal/HUD?src=/federal_housing_administration/healthcare_facilities/residential_care

• Section 232 Handbook http://portal.hud.gov/hudportal/HUD?src=/federal_housing_administration/healthcare_facilities/residential_care

• HUD FHA-Approved Lenders http://portal.hud.gov/hudportal/documents/huddoc?id=aprvlend.pdf

• 24 CFR 232 http://www.ecfr.gov/cgi-bin/text-idx?SID=f8e170da047b788a6749cfeb3c9535c9&node=pt24.2.232&rgn=div5

Resources





http://portal.hud.gov/hudportal/documents/huddoc?id=aprvlend.pdf

http://www.ecfr.gov/cgi-bin/text-idx?SID=f8e170da047b788a6749cfeb3c9535c9&node=pt24.2.232&rgn=div5






106

• 24 CFR 232 http://www.ecfr.gov/cgi-bin/text-idx?SID=f8e170da047b788a6749cfeb3c9535c9&node=pt24.2.232&rgn=div5

• 24 CFR 241 http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=f8e170da047b788a6749cfeb3c9535c9&ty=HTML&h=L&n=pt24.2.241&r=PART

• Summary of 223(f) Refinancing Program http://portal.hud.gov/hudportal/HUD?src=/program_offices/housing/mfh/progdesc/purchrefi223f

• Summary of 223(a)(7) Refinancing Program http://www.hud.gov/offices/adm/hudclips/letters/mortgagee/files/93-39ml.txt

Resources (continued)



http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=f8e170da047b788a6749cfeb3c9535c9&ty=HTML&h=L&n=pt24.2.241&r=PART



http://portal.hud.gov/hudportal/HUD?src=/program_offices/housing/mfh/progdesc/purchrefi223f



http://www.hud.gov/offices/adm/hudclips/letters/mortgagee/files/93-39ml.txt



Contact: Shelley M. McCracken-Rania Office of Healthcare Programs [email protected] (202) 402-5366 or (877) HLTH-FHA www.hud.gov/healthcare


THANK YOU

Office of Healthcare Programs 1-877-HLTH-FHA www.hud.gov/healthcare


Questions