CMS SOM App. Z, Tag E-0009

§482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4),

§485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4),

§494.62(a)(4)

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

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

[annually for LTC facilities]. The plan must do the following:]

(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. *

* [For ESRD facilities only at §494.62(a)(4)]: (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. The dialysis facility must contact the local emergency

preparedness agency at least annually to confirm that the agency is aware of the

dialysis facility’s needs in the event of an emergency.

Interpretive Guidelines applies to: §403.748(a)(4), §416.54(a)(4), §418.113(a)(4),

§441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4),

§484.102(a)(4), §485.68(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4),

§486.360(a)(4), §491.12(a)(4), §494.62(a)(4).

NOTE: This does not apply to Transplant Programs.

Cooperation and Collaboration

While the responsibility for ensuring a coordinated disaster preparedness response lies

upon the state and local emergency planning authorities, the facility must have a process

to engage in collaborative planning for an integrated emergency response. The facility

must include this integrated response process in its emergency plan. Facilities are

encouraged to participate in a healthcare coalition as it may provide assistance in

planning and addressing broader community needs that may also be supported by local

health department and emergency management resources. While every detail of the

cooperation and collaboration process is not required to be documented in writing, it is

expected that the facility has documented sufficient details to support verification of the

process.

When deciding on ways to meet public health emergency needs in their community,

facilities are expected to engage and coordinate with their local healthcare systems

(including any emergency-related Alternate Care Sites), and their local and state health

departments, and federal agency staff and also encouraged to engage with their

healthcare coalitions, as applicable. Facility awareness of the state’s emergency

preparedness programs and pandemic plan ensures coordination occurs with the

community. Coordination and communications between facilities and their public health

emergency officials is instrumental in ensuring a collaborative environment during a

disaster. Coordination should be pre-planned and facility management should know the

state and local emergency contacts (further defined within a facilities communication

plan).

We also note that under state licensure or their accreditation requirements, facilities may

still be required to document their collaboration with local, tribal, regional, State, and

Federal emergency preparedness officials. We recommend facilities contact their State

Survey Agency (SA) and/or accrediting organizations (AO) to determine if any additional

requirements exist.

Additional Requirement for ESRD

For ESRD facilities, §494.120(c)(2) of the ESRD Conditions for Coverage on Special

Purpose Dialysis Facilities describes the requirements for ESRD facilities that are set up

in an emergency (i.e., an emergency circumstance facility) which are issued a unique

CMS Certification Number (CCN). ESRD facilities must incorporate these specific

provisions into the coordination requirements under this standard.

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

annually for LTC facilities only.

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.

• For ESRD facilities, ask facility leadership to describe their process for contacting

the local public health and emergency management agency public official at least 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.