CMS SOM App. Z, Tag E-0017

[(b) Policies and procedures. The HHA 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) The plans for the HHA’s patients during a natural or man-made disaster.

Individual plans for each patient must be included as part of the comprehensive

patient assessment, which must be conducted according to the provisions at §484.55.

Interpretive Guidelines for §484.102(b)(1).

HHAs must include policies and procedures in its emergency plan for ensuring all

patients have an individualized plan in the event of an emergency. That plan must be

included as part of the patient’s comprehensive assessment.

For example, discussions to develop individualized emergency preparedness plans could

include potential disasters that the patient may face within the home such as fire hazards,

flooding, tornados, and EIDs; and how and when a patient is to contact local emergency

officials. Discussions may also include patient, care providers, patient representative, or

any person involved in the clinical care aspects to educate them on steps that can be taken

to improve the patient’s safety. The individualized emergency plan should be in writing

and could be as simple as a detailed emergency card to be kept with the patient. HHA

personnel should document that these discussions occurred and also keep a copy of the

individualized emergency plan in the patient’s file as well as provide a copy to the patient

and or their caregiver.

Additionally, HHAs should consider potential contingency operations within their

policies. For example, how will the HHA ensure the appropriate discipline/staff perform

the required initial and comprehensive assessments when access to residences may be

hindered due to an emergency? While some contingency plans may include requests for

Section 1135(b) emergency waiver flexibility during a declared public health emergency

(requiring CMS pre-approval prior to use), HHAs are encouraged to plan ahead for the

potential use of alternative staffing options/professions, acting in accordance with their

state scope of practice laws.

For additional information on 1135 Waivers, please visit:

https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Resources/Waivers-and-flexibilities and

also the CMS Frequently Asked Questions, Emergency-Related Policies and Procedures

That May Be Implemented Without § 1135 Waivers, at https://www.cms.gov/about-cms/agency-information/emergency/downloads/consolidated_medicare_ffs_emergency_qsas.pdf

Survey Procedures

• Through record review, verify that each patient has an individualized emergency plan

documented as part of the patient’s comprehensive assessment.

• Does the HHA have a process related to how to continue to meet the requirements for

individualized care plans?