CMS SOM App. Z, Tag E-0013

§483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.625(b), §485.727(b),

§485.920(b), §486.360(b), §491.12(b), §494.62(b).

(b) Policies and procedures. [Facilities] 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.

*[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility 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

annually.

*Additional Requirements for PACE and ESRD Facilities:

*[For PACE at §460.84(b):] Policies and procedures. The PACE organization 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 address management of medical and

nonmedical emergencies, including, but not limited to: Fire; equipment, power, or

water failure; care-related emergencies; and natural disasters likely to threaten the

health or safety of the participants, staff, or the public. The policies and procedures

must be reviewed and updated at least every 2 years.

*[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility

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. These emergencies include, but are not limited to,

fire, equipment or power failures, care-related emergencies, water supply

interruption, and natural disasters likely to occur in the facility’s geographic area.

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

§441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b),

§485.68(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b),

§494.62(b).

NOTE: This does not apply to Transplant Programs.

Facilities must develop and implement policies and procedures per the requirements of

this standard. The policies and procedures are expected to align with the identified

hazards within the facility’s risk assessment and the facility’s overall emergency

preparedness program.

We also recommend that facilities include strategies and

succession planning as well as contingencies which support their response to any

disaster or public health emergency (also see requirements at E-0024).

Facilities should also consider updates to their emergency preparedness policies and

procedures during a disaster, including planning for an emergency event with a duration

longer than expected. For instance, during public health emergencies such as

pandemics, the Centers for Disease Control and Prevention (CDC) and other public

health agencies may issue event-specific guidance and recommendations to healthcare

workers. Facilities should ensure their programs have policies in place to update or

provide additional emergency preparedness procedures to staff. This may include a

policy delegating an individual to monitor guidance by public health agencies and

issuing directives and recommendations to staff such as use of PPE when entering the

building; isolation of patients under investigation (PUIs); and, any other applicable

guidance in a public health emergency.

We are not specifying where the facility must have the emergency preparedness policies

and procedures. A facility may choose whether to incorporate the emergency policies

and procedures within their emergency plan or to be part of the facility’s Standard

Operating Procedures or Operating Manual. We are also not specifying the type of

documentation- i.e. hard copy, electronic or other system-based emergency plans.

However, the facility must be able to demonstrate compliance upon survey, therefore we

recommend that facilities have a central place to house the emergency preparedness

program documents (to include all policies and procedures) to facilitate review.

Furthermore, since the format of the documentation is at the discretion of the facility,

surveyors can identify a facility’s reviews and updates of the emergency program through

meeting minutes ( facilities need to be clear if the entire program or any specific policy

was reviewed and updated); through electronic or hard copy signatures on the table of

contents of the emergency program documentation; or another manner. Facilities should

clearly document the date of review and update and what the update entailed.

For ESRD and PACE Organizations, the policies and procedures must align with the risk

assessment and also include specific policies related to fire, equipment or power failures,

care-related emergencies, water supply interruption, and natural disasters likely to occur

in the facility’s geographic area. Care related emergencies may be specific to the patient

population served within these healthcare entities; as a result, the facility should ensure

that in the event of any EID, there are policies and procedures in place which protect the

health and safety of patients, to include but not limited to disinfection of patient stations

for ESRDs and notification of transportation considerations with local government and

community providers. We would expect ESRD and PACE Organizations to encompass

care related emergencies within their policies and procedures.

NOTE: This policy and procedure is required to be reviewed and updated annually for

LTC facilities only.

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 the policies and procedures have been

reviewed and updated at least every 2 years (annually for LTC facilities). Format is

at the discretion of the facility.