applying the 2012 life safety code® categorical waivers · 2/8/2018 4 requirements of the epp...

2/8/2018

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DEVELOPING A COMPREHENSIVE EMERGENCY PREPAREDNESS PROGRAM

The regulation focuses on 4 Core Elements:

Annual Risk Assessment & Emergency Planning (all-hazards approach)

Policies and Procedures

Communication Plan

Training and Testing

CMS: Emergency Preparedness Requirements

Nov. 15, 2017Implementation (“Compliance”)

Date

New Regulations Apply to 17 Providers, including LTC

Only applies to Medicare & Medicaid Providers

Applies to Long Term Care (& Dementia Care)

Applies to Home Health Agencies & Hospice

Does NOT apply to Assisted or Independent Living

BUT IF YOU ARE A CCRC, AL OR IL, YOUR RESIDENTS DESERVE AN EMERGENCY PREPARDNESS

PROGRAM TOO!

Table Of Contents

EPP MANAGEMENT PLAN: Policies and Planning

PROCEDURES APPLICABLE TO ALL HAZARD

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INCIDENT COMMAND SYSTEM

FULL BUILDING EVACUATION PLAN

EMERGENCY PROCEDURES FOR SPECIFIC EVENTS

EMERGENCY LISTS

C.O.O.P. & RECOVERY PLAN

APPENDICES

Components of an Emergency Preparedness Program

Assessing Your Facility & Community Risk

The Hazard Vulnerability Assessment

The foundation for your plan • Identifies risk/threats – Facility & Community

• Development of procedures & Mitigation strategies

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Electrical Failure

Generator Failure

Transportation Failure

Fuel Shortage

Natural Gas

Water Loss

Sewer Loss

Fire Alarm Loss

Med Gas Loss

HVAC loss

IT Loss

Technological Events

Missing Resident

VIP

Labor Action

Civil Disobedience

Forensic Admission

Human Hazards

Step 1: The Annual Risk Assessment Step 1: Mitigation Plans



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EMERGENCY LISTS


APPENDICES

RPA: Components of an Emergency Preparedness Program

The Purpose of the EPP (see handout)

Develop an all-hazards planning approach that will be used for all threats to, and/or emergencies or disasters that may impact the campus.

Create the general framework of planning for preparedness, response, recovery and mitigation activities of the facility.

Reduce the vulnerability of residents, staff and visitors and the community, including the loss of life or injury, or the damage and loss of property resulting from natural, technological, and man-made disasters, by developing effective preparedness, response, recovery and mitigation plans.

Describe the facility’s role in coordinating with and supporting local, state and federal governments during an emergency or disaster.

Describe the types of disasters which are likely to impact the facility, from local emergencies to minor, major or catastrophic disasters.

Section A: Policies and Planning

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Requirements of the EPP

Policy and Organizational Statements

• Identifies how the EPP was developed and how the facility intends on ensuring its continued effectiveness.

Risk Assessment Process

• Describes the method in which the facility conducted the Hazard Vulnerability Assessment (HVA) to recognizing hazards that may affect the facility.


EPP Requirements

Risk Assessment

• Base the EPP on facility specific and community hazards. Engage community partners.

Resident and Family Information Sharing

• Proactively provide information on planning, response and communication.

Communications Planning

• Provides names and contact information for staff, entities providing services under arrangement, residents’ physicians, other healthcare facilities, volunteers and other emergency service agencies.


EPP Requirements

Continuity of Operations

• Plans to ensure continued services to include, but are not limited to, emergency procedures, vendor support, agreements with other healthcare facilities, mutual aid plan support and support from local/state emergency management.

• Plans need to address services provided and levels of care.

Plan Review and Updates

• Annual

Training and Testing Program

• Training & Testing Program will be conducted, reviewed and updated at least annually.




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EMERGENCY LISTS


APPENDICES

RPA: Customizable EPP

EOP Activation

Code Alert

• General Code Word for any disaster

• Determine need for emergency personnel

• Establishment of a command center (formal or simple)

• Return to normal work areas

• Review the specific emergency procedure

• Make appropriate notifications

Section B: Procedures Applicable To All Hazard Responses

EOP Activation

Notifications

• Emergency Services

• Administrator / Exec. Director

• Director of Nursing

• Maintenance Director

• Medical Director

• Regional Director


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Communications

Potential Methods

• Phone

• Cell

• Portable radios

• Fax lines

• Email

• Website

• Runners

• News Media / Social Media


Managing Resources & Assets

Prepare for 72-96 hours

Consumables

• Water (potable, non-potable, fire protection)

• Electric (generator & fuel)

• Boilers (fuel)

• Oxygen

• Food (perishable and dry)

• Linen

• Clinical Supplies

• Housekeeping Supplies





Security & Safety

• Campus / Building Lockdown

Managing Staff

• Off Duty Notifications

• Disaster Staffing

• Staff & Family Sheltering

• Sheltering Pets

• Psychological Support

• Emergency Credentialing



Managing Utilities

• Loss of Electric, Water, Gas, HVAC, etc.

• Loss of Communications

Managing Residents

• Census Reduction

• Morgue / Mass Fatality

• Surge Capacity




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EMERGENCY LISTS


APPENDICES


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Section C: Incident Command System

Consider use of the Nursing Home ICS

https://www.cahfdisasterprep.com/nhics

Key Concepts

The Leader

The Advisors

The Thinkers

The Payers

The Doers

The Getters


Tools to Operationalize Incident Command

Job Descriptions (Job Action Sheets)Lists of areas, communicationsForms for Incident Response




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APPENDICES


Section D: Full Building Evacuation Plan

Evacuation From a Healthcare FacilityIs the EXCEPTION, Not the Rule

Methodology

Prepare residents within units / departments

Move to an Internal Holding Area

Transport from the Holding Area to a stop-over point, receiving facilities, or discharge

https://www.cahfdisasterprep.com/nhics

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Key Components

Activation of a Labor Pool

Establishment of Internal Holding Areas

Coordination of Transportation

Determination of Receiving Sites

Resident Preparation / Packaging / Tracking

Labor Pool Unit Leader

Develop Evacuation Groups

• Floor Evacuation Groups

• Elevator Evacuation Groups

• Stairwell Evacuation Groups

• Discharge Floor Evacuation Groups

Evacuation Groups

Evacuating Floor Group Elevator Group

Stair Group

Discharge Floor Group

Holding Area

Holding Areas

HOLDING AREA LOCATION

PATIENT PICK-UP LOCATION

Main Dining Room Front Entrance

Activity Room Rear Ambulance Entrance

Unique considerations – Dementia, Ventilator, Behavioral, etc.

Transportation Resources

What transportation resources do you need to evacuate?

Conduct an assessment

• ALS / BLS Ambulances

• Wheelchair Transports

• Bus / Vehicle

Resident Preparation

Resident Evacuation Tracking Form (NHICS)

Package chart (including MAR, face sheet & nursing notes)

Package with personal belongings (i.e. glasses, dentures, hearing aids, etc.)

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Factors In Pre-Planning Vertical Routes

Can we use elevators?• Be prepared to use stairs only

Do all stairs allow re-entry back into the building?• Conduct a walk-though of all stairwells to ensure they

provide access back into the building

Factors In Pre-Planning Vertical Routes

Are stairs and elevators identified (numbers, letters, names, etc.)?

• Consider providing additional signage

Should specific stairs and elevators be identified for staff and emergency services?

• Consider designating certain stairs / elevators

Are some stairs and elevators wider or deeper than others?

• Focus on wide stairs with large landings and deep elevators that will accommodate a gurney

Determining Evacuation Sites

Stop-over point (often referred to as an Alternate Care Site)

• Local school, gym, church, community center, etc.

• Handicap accessible bathrooms, emergency power (see Survey Tool)

Relationships with other healthcare facilities • Local / Regional / State-wide

• Healthcare Coalition

• Corporate

Mutual Aid Plan



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EMERGENCY LISTS


APPENDICES


Active Shooter / Person with a Weapon

Bioterrorism / Terrorism

Bomb Threat / Suspicious Package

Carbon Monoxide Alarm Activation

Cyber-Attack

Civil Disturbance / Demonstrations

Contamination of Outside Air (fire, smoke, chemical)

Earthquake

Fire (placeholder)

Flood (Internal & External)

Section E: Specific Disaster Procedures

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Hazardous Material Spill or Leak

Hostage Taking

Hurricane

Missing Resident **

Natural Gas Leak

Snow Emergency / Ice Storm

Tornado / High Winds

Wildfire


Loss of Central Services • Air Conditioning / High Heat

• Cooking Ability

• Commercial Power / Emergency Power

• Fire Protection

• Heating System

• IT / Nurse Call / Telephone

• Oxygen / Vacuum

• Water / Sewer




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APPENDICES


FACILITY INFORMATION & KEY CONTACTS

Facility Information

Disaster Kit Contents

Emergency Response Agency Contacts

Emergency Bedding

Emergency Food

Emergency Transportation Equipment

Elevator Keys

Facility Vehicles

Section F: Emergency Resources and Lists

UTILITY MANAGEMENT

Emergency Utility Shut-off Locations

Generator Information

Vendor Sources of Fuel


CONTRACTORS / VENDORS

Housekeeping / Linen Service

Food Services Department

Transportation

Maintenance and Restoration

Nursing

Pharmacy

Respiratory Therapy


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EMERGENCY LISTS


APPENDICES


THREE PHASES OF RECOVERY

Immediate

Long Term Temporary

Full

The Recovery Plan serves as a checklist to achieve “Full” Recovery.

Section G: Disaster Recovery Plan



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APPENDICES


Appendix A: Hazard Vulnerability Assessment (HVA)• Facility Specific HVA

• Community HVA

• Evidence of HVA Annual Analysis & Review

Appendix B: Mutual Aid Agreements / Memorandum(s) of Understanding

Appendix C: Compliance Schedule / Calendar

Appendix D: Vendor Agreements

Appendix E: Evacuation Route Maps

Appendix F: Organizational Chart and Roster of Staff with Key Disaster Roles

Appendices

Appendix G: Resident and Responsible Party - Emergency Communications Plan

Appendix H: Staff Competency Post Training Test

Appendix I: Collaborative and Cooperative Planning Efforts Documentation

Appendix J: Annual Analysis and Review

Appendices

Training Programs - WHO

Initial training for new and existing staff, individuals providing services under arrangement, and volunteers consistent with their expected role

Training: Requirements

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Training Programs - WHEN

Provide training at least annually

Maintain documentation


Training Programs - WHO

Develop and maintain an emergency preparedness training and testing program based on the emergency plan

• Not prescriptive

• Variety of mechanisms

• Variety of topics


Training Programs - WHAT

Emergency Operations Plan

• Activation protocols

• Plan contents

• Accessing key information

• Immediate actions



Specific Procedures

Specialized Equipment



Incident Command Training

• ICS / NHICS

• National Incident Management System (NIMS)


The LTC Facility must conduct “unannounced” exercises to test the emergency plan at least annually:

Participate in a “full-scale exercise” that is community-based

Conduct an additional exercise that may include:

• A second “full-scale exercise” or individual facility exercise

• A tabletop exercise that meets the specific requirements

Analyze the response to, and maintain documentation of all drills, exercises and emergency events, and revise the facility’s emergency plan, as needed.

Annual Testing

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The Emergency Preparedness Program Survey

Common CMS E-Tags (see handout)

• HVA

• Volunteer

• 1135 Waiver & Alternate Care Sites

• Training

• Exercises

Emergency Preparedness Survey Takeaways

CMS Emergency Preparedness Deficiencies

E Tags Survey Takeaways

• E-0006 Community Based Risk Assessment

For LTC facilities at §483.73(a)(1): Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.

Contact local / regional Emergency Management

Conduct an internet search

Integrate community hazards / risks into the facility HVA



• E-0022 Shelter in Place Plan

At a minimum, the policies and procedures must address the following: A means to shelter in place for patients, staff, and volunteers who remain in the facility.

• E-0024 Volunteers

At a minimum, the policies and procedures must address the following: The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.




• E-0026 1135 Waivers

At a minimum, the policies and procedures must address the following: The role of the facility under a waiver declared by the Secretary, in accordance with Section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.

Generally referred to as a “Stop-Over Point” in the mutual aid plans.




• E-0035 Resident & Family Communications

The communication plan must include all of the following: A method for sharing information from the emergency plan, that the facility has determined is appropriate, with residents [or clients] and their families or representatives.

• E-0039 Community Based Exercise

Participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based.


THANK YOU

Paul McManusAssistant Manager

[email protected]

mailto:[email protected]

applying the 2012 life safety code® categorical waivers · 2/8/2018 4 requirements of the epp...

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