CMS SOM App. W, Tag C-0950

The CAH must comply with all applicable Federal, State, and local emergency

preparedness requirements. The CAH must develop and maintain a comprehensive

emergency preparedness program, utilizing an all-hazards approach. The emergency

preparedness plan must include, but not be limited to, the following elements:

(a) Emergency plan. The CAH must develop and maintain an emergency preparedness

plan that must be reviewed and updated at least every 2 years. The plan must do all of the

following:

(1) Be based on and include a documented, facility-based and community-based

risk assessment, utilizing an all-hazards approach.

(2) Include strategies for addressing emergency events identified by the risk

assessment.

(3) Address patient population, including, but not limited to, persons at-risk; the

type of services the CAH has the ability to provide in an emergency; and

continuity of operations, including delegations of authority and succession plans.

(4) Include a process for cooperation and collaboration with local, tribal,

regional, State, and Federal emergency preparedness officials’ efforts to maintain

an integrated response during a disaster or emergency situation.

(b) Policies and procedures. The CAH must develop and implement emergency

preparedness policies and procedures, based on the emergency plan set forth in

paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the

communication plan at paragraph (c) of this section. The policies and procedures must

be reviewed and updated at least every 2 years. At a minimum, the policies and

procedures must address the following:

(1) The provision of subsistence needs for staff and patients, whether they

evacuate or shelter in place, include, but are not limited to—

(i) Food, water, medical, and pharmaceutical supplies;

(ii) Alternate sources of energy to maintain:

(A) Temperatures to protect patient health and safety and for the safe and

sanitary storage of provisions;

(B) Emergency lighting;

(C) Fire detection, extinguishing, and alarm systems; and

(D) Sewage and waste disposal.

(2) A system to track the location of on-duty staff and sheltered patients in the

CAH's care during an emergency. If on-duty staff and sheltered patients are

relocated during the emergency, the CAH must document the specific name and

location of the receiving facility or other location.

(3) Safe evacuation from the CAH, which includes consideration of care and

treatment needs of evacuees; staff responsibilities; transportation; identification

of evacuation location(s); and primary and alternate means of communication

with external sources of assistance.

(4) A means to shelter in place for patients, staff, and volunteers who remain in

the facility.

(5) A system of medical documentation that preserves patient information,

protects confidentiality of patient information, and secures and maintains the

availability of records.

(6) The use of volunteers in an emergency or other emergency staffing strategies,

including the process and role for integration of State or Federally designated

health care professionals to address surge needs during an emergency.

(7) The development of arrangements with other CAHs or other providers to

receive patients in the event of limitations or cessation of operations to maintain

the continuity of services to CAH patients.

(8) The role of the CAH 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.

(c) Communication plan. The CAH must develop and maintain an emergency

preparedness communication plan that complies with Federal, State, and local laws and

must be reviewed and updated at least every 2 years. The communication plan must

include all of the following:

(1) Names and contact information for the following:

(i) Staff.

(ii) Entities providing services under arrangement.

(iii) Patients' physicians.

(iv) Other CAHs and hospitals.

(v) Volunteers.

(2) Contact information for the following:

(i) Federal, State, tribal, regional, and local emergency preparedness staff.

(ii) Other sources of assistance.

(3) Primary and alternate means for communicating with the following:

(i) CAH's staff.

(ii) Federal, State, tribal, regional, and local emergency management

agencies.

(4) A method for sharing information and medical documentation for patients

under the CAH's care, as necessary, with other health care providers to maintain

the continuity of care.

(5) A means, in the event of an evacuation, to release patient information as

permitted under 45 CFR 164.510(b)(1)(ii).

(6) A means of providing information about the general condition and location of

patients under the facility's care as permitted under 45 CFR 164.510(b)(4).

(7) A means of providing information about the CAH's occupancy, needs, and its

ability to provide assistance, to the authority having jurisdiction or the Incident

Command Center, or designee.

(d) Training and testing. The CAH must develop and maintain an emergency

preparedness training and testing program that is based on the emergency plan set forth

in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section,

policies and procedures at paragraph (b) of this section, and the communication plan at

paragraph (c) of this section. The training and testing program must be reviewed and

updated at least every 2 years.

(1) Training program. The CAH must do all of the following:

(i) Initial training in emergency preparedness policies and procedures,

including prompt reporting and extinguishing of fires, protection, and where

necessary, evacuation of patients, personnel, and guests, fire prevention, and

cooperation with firefighting and disaster authorities, to all new and existing

staff, individuals providing services under arrangement, and volunteers,

consistent with their expected roles.

(ii) Provide emergency preparedness training at least every 2 years.

(iii) Maintain documentation of the training.

(iii) Demonstrate staff knowledge of emergency procedures.

(v) If the emergency preparedness policies and procedures are significantly

updated, the CAH must conduct training on the updated policies and

procedures.

(2) Testing. The CAH must conduct exercises to test the emergency plan at least

twice per year. The CAH must do the following:

(i) Participate in an annual full-scale exercise that is community-based; or

(A) When a community-based exercise is not accessible, conduct an

annual individual, facility-based functional exercise; or,

(B) If the CAH experiences an actual natural or man-made emergency

that requires activation of the emergency plan, the CAH is exempt from

engaging in its next required full-scale community-based or individual,

facility-based functional exercise following the onset of the emergency

event.

(ii) Conduct an annual additional exercise that may include, but is not limited

to the following:

(A) A second full-scale exercise that is community-based or an individual,

facility-based functional exercise; or

(B) A mock disaster drill; or

(C) A tabletop exercise or workshop that is led by a facilitator and

includes a group discussion, using a narrated, clinically-relevant

emergency scenario, and a set of problem statements, directed messages,

or prepared questions designed to challenge an emergency plan.

(iii) Analyze the CAH’s response to and maintain documentation of all drills,

tabletop exercises, and emergency events, and revise the CAH’s emergency

plan, as needed.

(e) Emergency and standby power systems. The CAH must implement emergency and

standby power systems based on the emergency plan set forth in paragraph (a) of this

section.

(1) Emergency generator location. The generator must be located in accordance

with the location requirements found in the Health Care Facilities Code (NFPA

99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5,

and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments

TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new

structure is built or when an existing structure or building is renovated.

(2) Emergency generator inspection and testing. The CAH must implement

emergency power system inspection and testing requirements found in the Health

Care Facilities Code, NFPA 110, and the Life Safety Code.

(3) Emergency generator fuel. CAHs that maintain an onsite fuel source to power

emergency generators must have a plan for how it will keep emergency power

systems operational during the emergency, unless it evacuates.

(f) Integrated healthcare systems. If a CAH is part of a healthcare system consisting of

multiple separately certified healthcare facilities that elects to have a unified and

integrated emergency preparedness program, the CAH may choose to participate in the

healthcare system's coordinated emergency preparedness program. If elected, the unified

and integrated emergency preparedness program must do all of the following:

(1) Demonstrate that each separately certified facility within the system actively

participated in the development of the unified and integrated emergency

preparedness program.

(2) Be developed and maintained in a manner that takes into account each

separately certified facility's unique circumstances, patient populations, and

services offered.

(3) Demonstrate that each separately certified facility is capable of actively using

the unified and integrated emergency preparedness program and is in compliance

with the program.

(4) Include a unified and integrated emergency plan that meets the requirements

of paragraphs (a)(2), (3), and (4) of this section. The unified and integrated

emergency plan must also be based on and include—

(i) A documented community-based risk assessment, utilizing an all-hazards

approach.

(ii) A documented individual facility-based risk assessment for each

separately certified facility within the health system, utilizing an all-hazards

approach.

(5) Include integrated policies and procedures that meet the requirements set

forth in paragraph (b) of this section, a coordinated communication plan and

training and testing programs that meet the requirements of paragraphs (c) and

(d) of this section, respectively.

(g) The standards incorporated by reference in this section are approved for

incorporation by reference by the Director of the Office of the Federal Register in

accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from

the sources listed below. You may inspect a copy at the CMS Information Resource

Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and

Records Administration (NARA). For information on the availability of this material at

NARA, call 202-741-6030, or go to

http://www.archives.gov/federal__register/code__of__federal__regulations/ibr__locatio

ns.html. If any changes in this edition of the Code are incorporated by reference, CMS

will publish a document in the Federal Register to announce the changes.

(1) National Fire Protection Association, 1 Batterymarch Park, Quincy, MA

02169, www.nfpa.org, 1.617.770.3000.

(i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11,

2011.

(ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11,

2011.

(iii) TIA 12-3 to NFPA 99, issued August 9, 2012.

(iv) TIA 12-4 to NFPA 99, issued March 7, 2013.

(v) TIA 12-5 to NFPA 99, issued August 1, 2013.

(vi) TIA 12-6 to NFPA 99, issued March 3, 2014.

(vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011.

(viii) TIA 12-1 to NFPA 101, issued August 11, 2011.

(ix) TIA 12-2 to NFPA 101, issued October 30, 2012.

(x) TIA 12-3 to NFPA 101, issued October 22, 2013.

(xi) TIA 12-4 to NFPA 101, issued October 22, 2013.

(xii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010

edition, including TIAs to chapter 7, issued August 6, 2009.

(2) [Reserved]