CMS SOM App. Z, Tag E-0018

§460.84(b)(2), §482.15(b)(2), §483.73(b)(2), §483.475(b)(2), §485.625(b)(2),

§485.920(b)(1), §486.360(b)(1), §494.62(b)(1).

[(b) Policies and procedures. The [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 [annually for

LTC facilities]. At a minimum, the policies and procedures must address the

following:]

[(2) or (1)] A system to track the location of on-duty staff and sheltered patients in

the [facility’s] care during an emergency. If on-duty staff and sheltered patients are

relocated during the emergency, the [facility] must document the specific name and

location of the receiving facility or other location.

*[For PRTFs at §441.184(b), LTC at §483.73(b), ICF/IIDs at §483.475(b), PACE at

§460.84(b):] Policies and procedures. (2) A system to track the location of on-duty

staff and sheltered residents in the [PRTF’s, LTC, ICF/IID or PACE] care during

and after an emergency. If on-duty staff and sheltered residents are relocated

during the emergency, the [PRTF’s, LTC, ICF/IID or PACE] must document the

specific name and location of the receiving facility or other location.

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

(ii) Safe evacuation from the hospice, which includes consideration of care and

treatment needs of evacuees; staff responsibilities; transportation; identification of

evacuation location(s) and primary and alternate means of communication with

external sources of assistance.

(v) A system to track the location of hospice employees’ on-duty and sheltered

patients in the hospice’s care during an emergency. If the on-duty employees or

sheltered patients are relocated during the emergency, the hospice must document

the specific name and location of the receiving facility or other location.

*[For CMHCs at §485.920(b):] Policies and procedures. (2) Safe evacuation from the

CMHC, which includes consideration of care and treatment needs of evacuees; staff

responsibilities; transportation; identification of evacuation location(s); and

primary and alternate means of communication with external sources of assistance.

*[For OPOs at § 486.360(b):] Policies and procedures. (2) A system of medical

documentation that preserves potential and actual donor information, protects

confidentiality of potential and actual donor information, and secures and maintains

the availability of records.

*[For ESRD at § 494.62(b):] Policies and procedures. (2) Safe evacuation from the

dialysis facility, which includes staff responsibilities, and needs of the patients.

Interpretive Guidelines applies to: §403.748(b)(2), §416.54(b)(1), §418.113(b)(6)(ii)

and (v), §441.184(b)(2), §460.84(b)(2), §482.15(b)(2), §483.73(b)(2), §483.475(b)(2),

§485.625(b)(2), §485.920(b)(1), §486.360(b)(1), §494.62(b)(1).

NOTE: This does not apply to Transplant Programs, HHAs, Clinics, Rehabilitation

Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy

and Speech-Language Pathology Services, RHCs/FQHCs.

Facilities must develop a means to track patients and on-duty staff in the facility’s care

during an emergency event. In the event staff and patients are relocated, the facility must

document the specific name and location of the receiving facility or other location for

sheltered patients and on-duty staff who leave the facility during the emergency.

CMHCs, PRTF’s, LTC facilities, ICF/IIDs, PACE organizations and ESRD Facilities are

required to track the location of sheltered patients and staff during and after an

emergency.

We are not specifying which type of tracking system should be used; rather, a facility has

the flexibility to determine how best to track patients and staff, whether it uses an

electronic database, hard copy documentation, or some other method. However, it is

important that the information be readily available, accurate, and shareable among

officials within and across the emergency response systems as needed in the interest of

the patient. It is recommended that a facility that is using an electronic database consider

backing up its computer system with a secondary source, such as hard copy

documentation in the event of power outages. The tracking systems set up by facilities

may want to consider who is responsible for compiling/securing patient records and what

information is needed during tracking a patient throughout an evacuation. A number of

states already have such tracking systems in place or under development and the systems

are available for use by health care providers and suppliers. Additionally, tracking of

staff can often be more challenging based on the mechanism used for signing in and out

for payment of staff based on hours worked, especially in the event of a power failure.

Facilities can consider implementing a staff tracking system such as designating an area

or protocol to check in with a designated person(s) during the emergency.

Facilities are encouraged to leverage the support and resources available to them through

local and national healthcare systems, healthcare coalitions, and healthcare organizations

for resources and tools for tracking patients. While collaboration with healthcare

coalitions is encouraged, it is not a requirement.

Though the precise details of the actual

collaboration with state and local emergency officials is not required to be documented,

it is expected that sufficient information is documented to support verification of the

process as part of the investigation.

Facilities are not required to track the location of patients who have voluntarily left on

their own, or have been appropriately discharged, since they are no longer in the facility’s

care. However, this information must be documented in the patient’s medical record

should any questions later arise as to the patient’s whereabouts.

We also recommend facilities ensure they follow their evacuation procedures as outlined

under this section during disasters and emergencies. Facilities are required follow all

state/local mandates or requirements under most CoPs/CfCs. If your local community,

region, or state declares a state of emergency and is requiring a mandatory evacuation of

the area, facilities should abide by these laws and mandates.

NOTE: If an ASC is able to cancel surgeries and close (meaning there are no patients or

staff in the ASC), this requirement of tracking patients and staff would no longer be

applicable. Similarly to ESRD standard practices, if an emergency was imminent and

able to be predicted (i.e. inclement weather conditions, etc.) we would expect that ASCs

cancel surgeries and cease operations, which would eliminate the need to track patients

and staff.

Survey Procedures

• Ask staff to describe and/or demonstrate the tracking system used to document

locations of patients and staff.

• Verify that the tracking system is documented as part of the facilities’ emergency

plan policies and procedures.