CMS SOM App. Z, Tag E-0008

[(a) Emergency Plan. The OPO 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 the type of hospitals with which the OPO has agreements; the type of

services the OPO has the capacity to provide in an emergency; and continuity of

operations, including delegations of authority and succession plans.

Interpretive Guidelines for §486.360(a)(3).

The emergency plan must address the type of hospitals with which the OPO has

agreements and the types of services that the OPO would be able to provide in an

emergency. The OPO’s emergency preparedness plan must address/include the type of

hospitals in which the OPO has an agreement. However, the emergency preparedness

plan is not required to be included as a part of each agreement that the OPO has with

their hospitals. The emergency plan must also 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 staff 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 necessary. During times of emergency, facilities must

have internal employees who are capable of assuming various critical roles in the event

that current staff and leaders are not available. At a minimum, facilities should designate

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.

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 ASPR when developing strategies

for ensuring continuity of operations.

Survey Procedures

Interview leadership and ask them to describe the following:

• Services the OPO would be able to provide during an emergency;

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

• Delegations of authority and succession plans.

• How the OPO has included/addressed all of the hospitals with which it has

agreements into its emergency plan.

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