CMS SOM App. Z, Tag E-0016

[(b) Policies and procedures. The hospice 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. At a minimum,

the policies and procedures must address the following:

(1) Procedures to follow up with on duty staff and patients to determine services

that are needed, in the event that there is an interruption in services during or due

to an emergency. The hospice must inform State and local officials of any on-duty

staff or patients that they are unable to contact.

Interpretive Guidelines for §418.113(b)(1).

Hospices have the flexibility to determine how best to develop these policies and

procedures. For administrative purposes, all hospices should already have some

mechanism in place to keep track of patients and staff contact information. However, the

information regarding patient services that are needed during or after an interruption in

their services and on-duty staff and patients that were not able to be contacted must be

readily available, accurate, and shareable among officials within and across the

emergency response system, as needed, in the interest of the patient.

Hospices must develop policies and procedures that address the use of hospice employees

in an emergency and the hospices’ potential surge needs; accordingly, hospices should

give consideration to their roles during a natural disasters and emerging infectious

diseases outbreaks or pandemics. Depending on the type of emergency, hospice staff

must develop policies and procedures to maintain the continuity of services to hospice

patients and should account for variability in the services which they provide- including

planning considerations for inpatient versus outpatient hospices and that in a given

emergency either setting may need to transfer patients to different healthcare settings

based on needs.

Hospices must develop policies and procedures which address the requirement to follow

up with on duty staff and patients to determine services that are needed, in the event that

there is an interruption in services during or due to an emergency. These policies and

procedures should include considerations such as but not limited to:

• Staffing shortages;

• Staff ability to provide safe care, to include any potential needs such as PPE;

• Care needs of the patients- inpatient or in home-based settings and potential

equipment needs;

• Screening phone calls prior to arrival and screening questions prior to entry into

a home

• Ways to decontaminate equipment and procedures to limit equipment taken into

homes

Additionally, since hospices must inform local and state officials of any on-duty staff or

patients that they are unable to contact, the policies and procedures should align with the

facility’s communication plans outlined under §418.113(c). These policies and

procedures should outline the timeframes for check-in with the facility’s designated

individual (e.g. staff check-in’s every 2 or 4 hours while on shift, and every 8 while off-duty).

A level of pre-coordination activities with state and local emergency officials may be

needed. Hospices should work with their state and local officials to determine how to

coordinate the reporting of staff or patients who cannot be contacted. Hospices should

also account for contingency planning in the event that some staff are unaccounted for

and how this relates to providing patient care.

Survey Procedures

• Review the emergency plan to verify it includes policies and procedures for following

up with staff and patients.

• Interview a staff member or leadership and ask them to explain the procedures in

place in the event they are unable to contact a staff member or patient.