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Cascade Pacific Fire Protection Consulting LLC

george.crosiar@gmail.com / 503-949-4259 (cell)

George Crosiar

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CMS Final Rule

• Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers

• Published September 16, 2016

• Applies to all 17 provider and supplier types

• Implementation date November 15, 2017

• Compliance required for participation in Medicare

• Emergency Preparedness is a Condition of Participation of many already required

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Program Core Elements

Policies and Procedures

Risk Assessment and Planning Policies and Procedures

Communication Plan Training and Testing

Emergency Preparedness

ProgramEmergency

PlanEmergency &

Standby Power Systems

Risk Assessment and Planning

• Develop an emergency plan based on a risk assessment.

• Perform risk assessment using an “all-hazards” approach, focusing on capacities and capabilities.

• Update emergency plan at least annually.

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All-Hazards Approach:

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Policies and Procedures

• Develop and implement policies and procedures based on the emergency plan and risk assessment.

• Policies and procedures must address a range of issues including subsistence needs, evacuation plans, procedures for sheltering in place, tracking patients and staff during an emergency.

• Review and update policies and procedures at least annually.

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Communication Plan

• Develop a communication plan that complies with both Federal and State laws.

• Coordinate patient care within the facility, across health care providers, and with state and local public health departments and emergency management systems.

• Review and update plan annually.

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Training and Testing Program

• Develop and maintain training and testing programs, including initial training in policies and procedures.

• Demonstrate knowledge of emergency procedures and provide training at least annually.

• Conduct drills and exercises to test the emergency plan.

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Training & Testing Program Definitions

• Facility-Based: When discussing the terms “all-hazards approach” and facility-based risk assessments, we consider the term “facility-based” to mean that the emergency preparedness program is specific to the facility. Facility-based includes, but is not limited to, hazards specific to a facility based on the geographic location; Patient/Resident/Client population; facility type and potential surrounding community assets (i.e. rural area versus a large metropolitan area).

• Full-Scale Exercise: A full scale exercise is a multi-agency, multijurisdictional, multi-discipline exercise involving functional (for example, joint field office, emergency operation centers, etc.) and ‘‘boots on the ground’’ response (for example, firefighters decontaminating mock victims).

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Training & Testing Program Definitions

• Table-top Exercise (TTX): A table-top exercise is a group discussion led by a facilitator, using narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. It involves key personnel discussing simulated scenarios, including computer-simulated exercises, in an informal setting. TTXs can be used to assess plans, policies, and procedures.

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Training & Testing Requirements

• Facilities are expected to meet all Training and Testing Requirements by the implementation date (11/15/17).

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

• Conduct an additional exercise that may include, but is not limited to the following:

‒ A second full-scale exercise that is individual, facility-based.

‒ A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.

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Final Rule- Provider Specific Requirements

• Long-term care facilities must share information from the emergency plan with residents and family members or representatives.

• Under the Policies and Procedures, Standard (b) there are requirements for subsistence needs and temperature controls.

• Additional requirements for long-term care facilities are located within the Final Rule under Standard (e) for Emergency Power and Stand-by Systems.

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Compliance

• Facilities are expected to be in compliance with the requirements by 11/15/2017.

• In the event facilities are non-compliant, the same general enforcement procedures will occur as is currently in place for any other conditions or requirements cited for non-compliance.

• Training for surveyors is available now.

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“E” Tags

• 26 “E” tags

• Covers all LTC facility EP requirements• Enforced by OSFM Compliance Specialists

• 0001• 0004• 0006• 0007• 0009• 0013• 0015• 0018• 0020

• 0022• 0023• 0024• 0025• 0026• 0029• 0030• 0031• 0032

• 0033• 0034• 0035• 0036• 0037• 0039• 0041• 0042

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https://asprtracie.s3.amazonaws.com/documents/aspr-

tracie-cms-ep-rule-long-term-care.pdf

NFPA 99

Health Care Facilities Code2012 Edition

Chapter 1 Administration1.3 Application.1.3.1 This code shall apply to all health care facilities otherthan home care.

Chapter 12 Emergency Management12.1* Scope. This chapter shall provide those with the responsibility for emergency management in new and existing health care facilities with the criteria to develop an emergency management program.12.1.1* General.12.1.1.1 This chapter shall provide those with the responsibility for emergency management in health care facilities with the criteria to assess, mitigate, prepare for, respond to, and recover from emergencies of any origin.12.1.1.2 This chapter shall be the source for emergency management in health care facilities and is based on the foundations of NFPA 1600, Standard on Disaster/Emergency Management and Business Continuity Programs.12.1.1.3 This chapter shall aid in developing, maintaining, and evaluating effective emergency management programs in new and existing facilities.

12.1.2 Applicability. This chapter shall be applicable to any health care facility that is intended to provide medical care during an emergency or maintain services for patients during a disaster and for the protection of visitors and staff.

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ComplianceSurvey Procedures

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Emergency Preparedness

Program & Plan

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Emergency Plan

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Risk Assessment & Planning

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Patient Populations & Continuity Of Operations

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Cooperation & Colaboration

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Policies & Procedures

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Subsistence Needs

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Tracking Patients & Staff

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Sheltering in Place

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Volunteers & Staffing

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Continuity of Services

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Waivers

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Communication Plan

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Resources for Assistance

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Means of Communication

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Sharing Patient Information

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Facility Needs & Occupancy

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Sharing Emergency Plan Information

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Training & Testing

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Emergency & Standby Power

Systems

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K111 Building Rehabilitation Repair, Renovation, Modification, or

Reconstruction Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following:

Requirements of Chapter 18 and 19. Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6. 18.1.1.4.3,

19.1.1.4.3, 43.1.2.1

Life Safety Code “K” Tag

3.3.228 Renovation. The replacement in kind, strengthening, or upgrading of building elements, materials, equipment, or fixtures that does not result in a reconfiguration of the building or spaces within.

Life Safety Code

18.1.1.4.3 Rehabilitation.18.1.1.4.3.1 For purposes of the provisions of this chapter, the following shall apply:(1) A major rehabilitation shall involve the modification of more than 50 percent, or more than 4500 ft2 (420 m2), of the area of the smoke compartment.(2) A minor rehabilitation shall involve the modification of not more than 50 percent, and not more than 4500 ft2 (420 m2), of the area of the smoke compartment.18.1.1.4.3.2 Work that is exclusively plumbing, mechanical, fire protection system, electrical, medical gas, or medical equipment work shall not be included in the computation of the modification area within the smoke compartment.18.1.1.4.3.3* Where major rehabilitation is done in a non-sprinklered smoke compartment, the automatic sprinkler requirements of 18.3.5 shall apply to the smoke compartment undergoing the rehabilitation, and, in cases where the buildingis not protected throughout by an approved automatic sprinkler system, the requirements of 18.4.3.2, 18.4.3.3, and 18.4.3.8 shall also apply.18.1.1.4.3.4* Where minor rehabilitation is done in a non-sprinklered smoke compartment, the requirements of 18.3.5.1 shall not apply, but, in such cases, the rehabilitation shall not reduce life safety below the level required for new buildings or below the level of the requirements of 18.4.3 for non-sprinklered smoke compartment rehabilitation. (See 4.6.7.)

Life Safety Code

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4.6.7 Building Rehabilitation.4.6.7.1 Rehabilitation work on existing buildings shall be classified as one of the following work categories in accordance with 43.2.2.1:

(1) Repair(2) Renovation(3) Modification(4) Reconstruction(5) Change of use or occupancy classification(6) Addition

4.6.7.2 Rehabilitation work on existing buildings shall comply with Chapter 43.4.6.7.3 Except where another provision of this Code exempts a previously approved feature from a requirement, the resulting feature shall be not less than that required for existing buildings.4.6.7.4* Existing life safety features that exceed the requirements for new buildings shall be permitted to be decreased to those required for new buildings.4.6.7.5* Existing life safety features that do not meet the requirements for new buildings, but that exceed the requirements for existing buildings, shall not be further diminished.4.6.8 Provisions in Excess of Code Requirements. Nothing in this Code shall be construed to prohibit a better building construction type, an additional means of egress, or an otherwise safer condition than that specified by the minimum requirements of this Code.

Life Safety Code

Integrated Health Care Systems

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ResourcesFor

LTC Facilities

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Interpretive Guidelines

• The Survey & Certification Group (SCG) has developed Interpretive Guidelines (IGs) which will assist in implementation of the new regulation.

• The IGs will be formatted into one new Appendix within the State Operations Manual (SOM) applicable to all 17 provider/supplier types

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https://www.cms.gov/Medicare/Provider-Enrollment-and-

Certification/SurveyCertEmergPrep/Emergency-Prep-Rule.html

https://www.cms.gov/Medicare/Provider-Enrollment-and-

Certification/SurveyCertEmergPrep/Downloads/Advanced-Copy-SOM-

Appendix-Z-EP-IGs.pdf

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https://surveyortraining.cms.hhs.gov/d

ata/104/4ffb83eb-ce51-e711-9524-

0e63451df8f4/Linear/hhs_ep_m2l1t1/EP

%20Appendix%20Z-

%20Surveyor%20Understanding%20How

-To-Guide.pdf

https://asprtracie.hhs.gov/cmsrule

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http://www.oregon.gov/oha/ph/Prepa

redness/Partners/Pages/index.aspx

https://www.cms.gov/Medicare/Provider-Enrollment-and-

Certification/SurveyCertEmergPrep/Downloads/EP-Rule-Table-Provider-

Type.pdf

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http://www.oregon.gov/oha/PH/PREPAREDNESS/PARTNER

S/Documents/CMSEmergencyPreparednessFinalRuleCross

walk.pdf

Cascade Pacific Fire Protection Consulting LLC

george.crosiar@gmail.com / 503-949-4259 (cell)

George Crosiar