This section will be used to provide updates on our current weather situations:
THE CMS Survey process for Emergency Preparedness
Do you want to know what the surveyors are looking for? The following will give you a snapshot of what the surveyors will be asking for…….
E-0001 Survey Procedures
- Interview the facility leadership and ask him/her/them to describe the facility’s emergency preparedness program.
- Ask to see the facility’s written policy and documentation on the emergency preparedness program.
- For hospitals and CAHs only: Verify the hospital’s or CAH’s program was developed based on an all-hazards approach by asking their leadership to describe how the facility used an all-hazards approach when developing its program.
E-0004 Survey Procedures
- Verify the facility has an emergency preparedness plan by asking to see a copy of the plan.
- Ask facility leadership to identify the hazards (e.g. natural, man-made, facility, geographic, etc.) that were identified in the facility’s risk assessment and how the risk assessment was conducted.
- Review the plan to verify it contains all the required elements.
- Verify that the plan is reviewed and updated annually by looking for documentation of the date of the review and updates that were made to the plan based on the review.
E-0006 Survey Procedures
- Ask to see the written documentation of the facility’s risk assessments and associated strategies.
- Interview the facility leadership and ask which hazards (e.g. natural, man-made, facility, geographic) were included in the facility’s risk assessment, why they were included and how the risk assessment was conducted.
- Verify the risk-assessment is based on an all-hazards approach specific to the geographic location of the facility and encompasses potential hazards.
E-0007 Survey Procedures
Interview leadership and ask them to describe the following:
- The facility’s patient populations that would be at risk during an emergency event.
- Strategies the facility (except for an ASC, hospice, PACE organization, HHA, CORF, CMHC, RHC/FQHC and ESRD facility) has put in place to address the needs of at risk or vulnerable patient populations.
- Services the facility would be able to provide during an emergency.
- How the facility plans to continue operations during an emergency.
- Delegations of authority and succession plans.
Verify all the above are included in the written emergency plan.
E-0009 Survey Procedures
Interview facility leadership and ask them to describe their process for ensuring cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to ensure an integrated response during a disaster or emergency situation.
- Ask for documentation of the facility’s efforts to contact such officials and, when applicable, its participation in collaborative and cooperative planning efforts.
- For ESRD facilities, ask to see documentation that the ESRD facility contacted the local public health and emergency management agency public official at least annually to confirm that the agency is aware of the ESRD facility’s needs in the event of an emergency and know how to contact the agencies in the event of an emergency.
E-0013 Survey Procedures
Review the written policies and procedures which address the facility’s emergency plan and verify the following:
- Policies and procedures were developed based on the facility-and community-based risk assessment and communication plan, utilizing an all-hazards approach.
- Ask to see documentation that verifies that policies and procedures have been reviewed and updated on an annual basis.
E-0015 Survey Procedures
Verify the emergency plan includes policies and procedures for the provision of subsistence needs including, but not limited to, food, water and pharmaceutical supplies for patients and staff.
- Verify the emergency plan includes policies and procedures to ensure adequate alternate energy sources, including emergency power necessary to maintain:
o Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions
o Emergency lighting
o Fire detection, extinguishing, and alarm systems
- Verify the emergency plan includes policies and procedures to provide for sewage and waste disposal.
E-0017 Survey Procedures
- Through record review, verify that each patient has an individualized emergency plan documented as part of the patient’s comprehensive assessment.
E-0018 Survey Procedures
- Ask staff to describe and/or demonstrate the tracking system used to document locations of patients and staff.
- Verify that the tracking system is documented as part of the facilities’ emergency plan policies and procedures.
E-0019 Survey Procedures
- Review the emergency plan to verify it includes procedures to inform State and local emergency preparedness officials about patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment.
E-0021 Survey Procedures
- Verify that the HHA has included in its emergency plan these procedures to follow up with staff and patients and to inform state and local authorities when they are unable to contact any of them.
- Verify that the HHA has procedures in its emergency plan to follow up with on-duty staff and patients to determine the services that are needed, in the event there is an interruption in services during or due to an emergency.
- Ask the HHA to describe the mechanism to inform State and local officials of any on duty staff or patients that they are unable to contact.
E-0023 Survey Procedures
- Ask to see a copy of the policies and procedures that documents the medical record documentation system the facility has developed to preserves patient (or potential and actual donor for OPOs) information, protects confidentiality of patient (or potential and actual donor for OPOs) information, and secures and maintains availability of records.
E-0024 Survey Procedures
- Verify the facility has included policies and procedures for the use of volunteers and other staffing strategies in its emergency plan.
E-0029 Survey Procedures
- Verify that the facility has a written communication plan by asking to see the plan.
- Ask to see evidence that the plan has been reviewed (and updated as necessary) on an annual basis.
Joint Commission Continuity of Operations article
(Click on the words above to access the article)
Health Care Facility Based Training Opportunities
Are you in need of respiratory protection training, decontamination training, or exercise development and facilitation at your facility? If so, the coalition now offers emergency preparedness planning, training and exercise services for a very reasonable fee at your facility. You don’t have to drive to us, we come to you!! The grant from the Assistant Secretary of Preparedness and Response (ASPR) does not allow us to provide planning, training or exercise opportunities at a health care facility level, but we recognize the need to for this service and want you to know that it is available.
- Drill facilitation
- Emergency communications consultation
- Environmental safety and security risk assessments
- Evacuation equipment training
- Exercise facilitation
- Exercise planning and coordination
- First receiver decontamination training
- Hazard and vulnerability development
- Incident command system training
- Physical security and environmental design assessments
- Plan and documentation review and development
- Pressure point control tactics and self-defense
- Professional speaking on emergency preparedness topics
- Psychological first aid
- Respiratory protection – fit testing
- Verbal de-escalation
Please feel free to reach out to your regional representative if you have any questions.
Rachel Mockros: Rachel.firstname.lastname@example.org
Shawn Stoen: email@example.com
Don Sheldrew: Donald.firstname.lastname@example.org