CMS SOM App. Z, Tag E-0007

§482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3),

§485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3).

[(a) Emergency Plan. The [facility] must develop and maintain an emergency

preparedness plan that must be reviewed, and updated at least every 2 years. The

plan must do the following:]

(3) Address [patient/client] population, including, but not limited to, persons at-risk

;

the type of services the [facility] has the ability to provide in an emergency; and

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

*[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop

and maintain an emergency preparedness plan that must be reviewed, and updated

at least annually. The plan must do all of the following:

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

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

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

*NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF,

CMCH, RHC/FQHC, or ESRD facilities.]

Interpretive Guidelines applies to: §403.748(a)(3), §416.54(a)(3), §418.113(a)(3),

§441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3),

§484.102(a)(3), §485.68(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3),

§491.12(a)(3), §494.62(a)(3).

NOTE: This does not apply to Transplant Programs and OPOs.

Patient Population:

The emergency plan must specify the population served within the facility, such as

inpatients and/or outpatients, and their unique vulnerabilities in the event of an

emergency or disaster. A facility’s emergency plan must also address persons at-risk,

except for plans of ASCs, hospices, PACE organizations, HHAs, CORFs, CMHCs,

RHCs/FQHCs and ESRD facilities. As defined by the Pandemic and All-Hazards

Preparedness Act (PAHPA) of 2006, members of at-risk populations may have additional

needs in one or more of the following functional areas: maintaining independence,

communication, transportation, supervision, and medical care. In addition to those

individuals specifically recognized as at-risk in the PAHPA (children, senior citizens, and

pregnant women), “at-risk populations” are also individuals who may need additional

response assistance including those who have disabilities, live in institutionalized

settings, are from diverse cultures and racial and ethnic backgrounds, have limited

English proficiency or are non-English speaking, lack transportation, have chronic

medical disorders, or have pharmacological dependency. At-risk populations would also

include, but are not limited to, the elderly, persons in hospitals and nursing homes, people

with physical and mental disabilities as well as others with access and functional needs,

and infants and children. At-risk populations, in the event of emerging infectious diseases

and communicable diseases, may also include older adults and people of any age with

underlying medical conditions or who are immunocompromised, in which exposure may

place them to be at higher risk for severe illnesses.

Mobility & Transfers:

Mobility is an important part in effective and timely evacuations, and therefore facilities

are expected to properly plan to identify patients who would require additional assistance,

ensure that means for transport are accessible and available and that those involved in

transport, as well as the patients and residents are made aware of the procedures to

evacuate. For outpatient facilities, such as Home Health Agencies (HHAs), the

emergency plan is required to ensure that patients with limited mobility are addressed

within the plan.

The plan should also address ways the facility will address identified patient needs that

can’t be addressed by in house services in an emergency, such as just in time contracts or

emergency transfers. Ultimately, the delegations of authority and succession plans need

to include plans on how the facility ensures patient safety is protected and patients will

receive care at the facility or if transferred, under what circumstances transfers will occur.

Surge & Staffing

The emergency plan must also address the types of services that the facility would be

able to provide in an emergency. The emergency plan must identify which staff would

assume specific roles in another’s absence through succession planning and delegations

of authority. Succession planning is a process for identifying and developing internal

people with the potential to fill key business leadership positions in the company.

Succession planning increases the availability of experienced and capable employees that

are prepared to assume these roles as they become available. During times of emergency,

facilities must have employees who are capable of assuming various critical roles in the

event that current staff and leadership are not available. At a minimum, there should be a

qualified person who "is authorized in writing to act in the absence of the administrator or

person legally responsible for the operations of the facility." This does not mean that the

facility must have documentation which lists each role and the designee for those roles

within the same policy. Facilities may have a general plan which outlines the roles and

responsibilities of the different individuals (e.g. incident commander, public information

officer, patient liaison, etc.) and refers to those individuals by their titles. For example, a

Facility Incident Commander may be the Facility Administrator. Also, an Emergency

Department Charge Nurse of the Day may be the facility’s identified person as the Safety

Officer. However, if the facility chooses to follow this process without individual name

identification, the individual serving in the role during the time of the survey should be

able to adequately describe their role and responsibility during an emergency.

The emergency plan should also include ways the facility will respond to identified

patient needs that cannot be addressed by in-house services in an emergency, such as use

of just-in-time contracts or emergency transfers. As discussed under E-0001, CMS

recognizes the variability in terminology in continuity of operations, business continuity,

and other terms used by the emergency management industry. The intent behind this

requirement is to ensure continuity of operations, including emergency preparedness

succession planning, ultimately to ensure the facility has plans in place to continue

functioning during an emergency and provide care in a safe setting, which may require

some/all evacuations. Ultimately, the delegations of authority and succession plans,

which are different from the “continuity” plans, are documented plans which outline the

specific individuals and alternate/successors who can activate the facilities emergency

plans to ensure patient safety is protected and patients will receive care at the facility or

if transferred, under what circumstances transfers will occur.

General Considerations

In addition to the facility- and community-based risk assessment, continuity of operations

planning generally considers elements such as: essential personnel, essential functions,

critical resources, vital records and IT data protection, alternate facility identification and

location, and financial resources. Facilities are encouraged to refer to and utilize

resources from various agencies such as FEMA and Assistant Secretary for Preparedness

and Response (ASPR) when developing strategies for ensuring continuity of operations.

NOTE: This standard to the emergency preparedness plan must be reviewed and updated

annually for LTC facilities only.

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 that the facility would be able to provide during an emergency and any plans

to address services needed that cannot be provided by the facility during an

emergency as part of continuity of operations and services.

• How the facility plans to continue operations during an emergency;

• Delegations of authority and succession plans.

Verify that all of the above are included in the written emergency plan.

• If the facility has delegations and succession plans which identifies roles and

responsibilities over individual facility staff names (e.g. Safety Officer =

Emergency Department Charge Nurse or Pharmacy Department Lead), identify

the individual who would be designated in one of the roles and interview the

individual asking them to describe their role based on the facility’s emergency

program.