CMS SOM App. Z, Tag E-0015

§483.73(b)(1), §483.475(b)(1), §485.625(b)(1)

[(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 every 2 years [annually for LTC

facilities]. 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 the following:

(i) Food, water, medical and pharmaceutical supplies

(ii) Alternate sources of energy to maintain the following:

(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.

(D) Sewage and waste disposal.

*[For Inpatient Hospice at §418.113(b)(6)(iii):] Policies and procedures.

(6) The following are additional requirements for hospice-operated inpatient care

facilities only. The policies and procedures must address the following:

(iii) The provision of subsistence needs for hospice employees and patients,

whether they evacuate or shelter in place, include, but are not limited to the

following:

(A) Food, water, medical, and pharmaceutical supplies.

(B) Alternate sources of energy to maintain the following:

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

and sanitary storage of provisions.

(2) Emergency lighting.

(3) Fire detection, extinguishing, and alarm systems.

(C) Sewage and waste disposal.

Interpretive Guidelines applies to: §403.748(b)(1), §418.113(b)(6)(iii),

§441.184(b)(1), §460.84(b)(1), §482.15(b)(1), §483.73(b)(1), §483.475(b)(1),

§485.625(b)(1).

NOTE: This does not apply to ASCs, Outpatient Hospice Providers [applies to

inpatient hospices], Transplant Programs, HHA, CORFs, CMHCs, RHCs/FQHCs,

ESRD facilities.

Facilities must be able to provide for adequate subsistence for all patients and staff for the

duration of an emergency or until all its patients have been evacuated and its operations

cease. Facilities have flexibility in identifying their individual subsistence needs that

would be required during an emergency.

Provisions

There are no requirements or standards establishing a set amount of provisions to be

provided in facilities, for example ensuring availability of 72 hours’ worth of supplies.

However, some states laws or accrediting organization requirements do specify a set

amount or duration of subsistence items to have on hand, therefore facilities should check

with their state agencies and accrediting organizations to determine if any additional

requirements exist. Facilities also are required to continue to meet existing health and

safety standards, such as physical environment at §482.41(a)(1) for hospitals, which

address requirements like the

emergency power and lighting in at least the operating,

recovery, intensive care, and emergency rooms, and stairwells. In all other areas not

serviced by the emergency supply source, battery lamps and flashlights must be

available.. Provisions include, but are not limited to, food, pharmaceuticals and medical

supplies. Provisions should be stored in an area which is less likely to be affected by

disaster, such as storing these resources above ground-level to protect from possible

flooding. Additionally, when inpatient facilities determine their supply needs, they are

expected to consider the possibility that volunteers, visitors, and individuals from the

community may arrive at the facility to offer assistance or seek shelter.

This standard does not apply to outpatient facilities such as ASCs, Outpatient Hospice

providers, transplant programs, HHAs, CORFs, CMHCs, RHCs/FQHCs, and ESRD

facilities as it is expected that such outpatient providers would close and evacuate their

patients to a safer setting during the emergency. However, per subsection (b)(1),

inpatient providers must ensure that they have policies and procedures that address food,

water, medical/pharmaceutical needs for both staff and patients during an emergency,

regardless of whether they evacuate or not. Evacuation efforts may be delayed, therefore

facilities affected by this provision should account for patient and staff needs leading up

to or during an evacuation.

NOTE: Facilities should also consider subsistence needs of volunteers, visitors and other

individuals who are sheltering in the facility during an event. See subsection (b)(4).

Alternate Energy Sources & Temperatures

It is up to each individual facility, based on its risk assessment, to determine the

most appropriate alternate energy sources to maintain temperatures to protect

patient health and safety and for the safe and sanitary storage of provisions,

emergency lighting, fire detection, extinguishing, and alarm systems, and sewage

and waste disposal and continuity of treatments.

Facilities are not required to upgrade their alternate energy source or electrical systems,

but after review of their risk assessment may find it prudent to make modifications.

Regardless of the alternate sources of energy a facility chooses to utilize, it must be in

accordance with local and state laws, manufacturer requirements, as well as applicable

LSC requirements (for example, hospitals are required to have an essential electric

system with a generator that complies with NFPA 99 – Health Care Facilities Code and

associate reference documents).

Facilities must establish policies and procedures that determine how required heating and

cooling of their facility will be maintained during an emergency situation, as necessary, if

there were a loss of the primary power source. Facilities are not required to heat and cool

the entire building evenly, but must ensure safe temperatures are maintained in those

areas deemed necessary to protect patients,

other people who are in the facility, and for

provisions stored in the facility during the course of an emergency, as determined by the

facility risk assessment. If unable to meet the temperature needs, a facility should have a

relocation/evacuation plan (that may include internal relocation, relocation to other

buildings on the campus or full evacuation). The relocation/evacuation should take place

in a timely manner so as not to expose patients and residents to unsafe temperatures.

NOTE: For LTC facilities under 483.10(i)(6), there are additional requirements for

facilities who were initially certified after October 1, 1990 who must maintain a

temperature range of 71 (min) to 81 °F (max).

Facilities should include their Medicare

[and Medicaid, as applicable] certification date[s] in the front of their plan.

If used, portable generators should be connected to a facility’s electrical circuits via a

power transfer system as recommended by the generators’ manufacturer. A power

transfer system typically consists of a transfer switch, generator power cord and power

inlet box In accordance with manufacturer instructions and NFPA 70, Article 400.8,

individual extension cords should not to be run from portable generator outlet

receptacles to electrical appliances. If a facility’s risk assessment determines the best

way to maintain temperatures, emergency lighting, fire detection and extinguishing

systems and sewage and waste disposal would be through the use of a portable and

mobile generator, rather than a permanent generator, then the LSC provisions such as

generator testing, maintenance, etc. outlined under the NFPA guidelines requirements

would not be applicable, except for NFPA 70 - National Electrical Code.

Per NFPA 70, portable and mobile generators should:

• Have all wiring to each unit installed in accordance with the requirements of any

of the wiring methods in Chapter 3.

• Be designed and located to minimize the hazards that might cause complete

failure due to flooding, fires, icing, and vandalism.

• Be located so that adequate ventilation is provided. Typically, this may be

accomplished by locating a portable or mobile generator outside of the building.

• Be located or protected so that sparks cannot reach adjacent combustible material.

• Be operated, tested and maintained in accordance with manufacturer, local and/or

State requirements.

For requirements regarding permanently installed generators, please refer to applicable

NFPA Codes and Standards. If a health surveyor is unclear whether the facility is

complying with the alternate sources of energy and temperature requirements, the health

surveyor must consult with their LSC surveyors.

Extension cords or other temporary wiring devices may not be used to connect electrical

equipment in the facility to a portable and mobile generator due to the potential for shock,

fire, and tripping hazards when using such devices. For portable generators, they must

be connected and provide emergency power to a facility’s electrical system circuits via a

power transfer system as recommended by the generator manufacturer. A power transfer

system typically consists of a generator power supply cord, power inlet box mounted

outside, and transfer switch connected to the facility electrical panel.

The type of protection needed for the fuel stored by the facility for use by the portable

and mobile generator will depend on the amount of fuel stored and the location of the

storage, as per the appropriate NFPA standard.

If a facility has a permanent generator to maintain emergency power, LSC and NFPA 110

provisions such as generator location, testing, fuel storage and maintenance, etc. will

apply and the facility may be subject to LSC surveys to ensure compliance is met. Please

also refer to Tag E0041 Emergency and Standby Power Systems for additional

requirements for LTC facilities, CAHs and Hospitals.

As an example, some facilities have contracted services with companies who maintain

portable emergency generators for the facilities off-site. In the event of an emergency

where the facility is unable to reschedule patients or evacuate, the generators are brought

to the location in advance to assist in the event of loss of power. Facilities which are not

specifically required by the EP Final Rule to have a generator, but are required to meet

the provision for alternate sources of energy, may consider this approach for their facility.

Sewage & Waste Disposal

Facilities are not required to provide onsite treatment of sewage or waste, but must make

provisions for maintaining necessary services. In addition, we are not specifying

necessary services for sewage or waste management; however, facilities are required to

follow their current facility-type requirements (e.g., CoPs/CfCs) which may address these

areas. For example, LTC facilities are already required to meet Food Receiving and

Storage provisions at §483.35(i) Sanitary Conditions, which contain requirements for

keeping food off the floor and clear of ceiling sprinklers, sewer/waste disposal pipes, and

vents can also help maintain food quality and prevent contamination. Additionally,

ESRD facilities under current CfCs at §494.40(a)(4) are also required to have policies

and procedures for handling, storage and disposal of potentially infectious waste.

Additionally, we would expect facilities under this requirement to ensure current

practices are followed, such as those outlined by the Environmental Protection Agency

(EPA) and under State-specific laws. Maintaining necessary services may include, but

are not limited to, access to medical gases; treatment of soiled linens; disposal of bio-hazard materials for different infectious diseases; and may require additional assistance

from transportation companies for safe and appropriate disposal in accordance with

nationally accepted industry guidelines for emergency preparedness.

Additional General Guidance

As part of the cooperation and collaboration with emergency preparedness officials

required under subsection (a) (for example, §482.15(a)(4), facilities should also confer

with health department and emergency management officials to determine the types and

duration of energy sources that could be available to assist them in providing care to their

patient population during an emergency. As part of the risk assessment planning,

facilities should determine the feasibility of relying on these sources and plan

accordingly.

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

LTC facilities only.

Survey Procedures

• Verify the emergency plan includes policies and procedures for the provision of

subsistence needs including, but not limited to, food, water and pharmaceutical

supplies for patients and staff.

• Verify the emergency plan includes policies and procedures to ensure adequate

alternate energy sources, including emergency power necessary to maintain:

o Temperatures to protect patient health and safety and for the safe and sanitary

storage of provisions;

o Emergency lighting; and,

o Fire detection, extinguishing, and alarm systems.

• Verify the emergency plan includes policies and procedures to provide for sewage

and waste disposal.